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Understanding HH PPS CMS’ Home Health Prospective Payment System 2017

Learn about Medicare reimbursement for home health services, diagnosis group scoring, and construction of HIPPS codes in the Home Health Prospective Payment System.

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Understanding HH PPS CMS’ Home Health Prospective Payment System 2017

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  1. Understanding HH PPS CMS’ Home Health Prospective Payment System 2017 Michelle Mantel, MSN, GNP, RN, COS-C, HCS-D, BCHH-C Manager of System Integration & Coding Analytics

  2. Objectives The learner will understand and be able to: • Explain how Medicare and other PPS payers reimburse for home health with regard to: • Episode timing • Diagnosis groups and diagnosis group scoring • Clinical scoring • Functional scoring • Service utilization scoring • Changes in case-mix weight of diagnoses • Non-routine supply (NRS) scoring • Construction of HIPPS (Health Insurance Prospective Payment System) codes

  3. Definitions • Home Health Prospective Payment System (HH-PPS) • The system of payment by which home health agencies are reimbursed for services rendered • Base payment that is adjusted depending upon a patient’s health condition, care needs, and the geographic wage index – HHA location • The adjustment for the health condition/clinical and service needs of the patient is called the case-mix adjustment. • Outlier payment adjustments to pay for sickest patients • Partial end payment (PEP) adjustments for patients with < 5 visits in an episode of care • Home Health Resource Group (HHRG) • One of 153 case-mix groups used for patient classification

  4. Diagnosis Groups • Diagnoses • There are 22 different diagnosis groups. • Each group is assigned an ID number for the software to identify. • Diagnoses and numbers are sequenced alphabetically. • Scoring • Able to earn points from more than one diagnosis group. • Each group can earn points only once per episode. • If the primary diagnosis and a secondary diagnosis are in the same diagnosis group, points are awarded for the primary diagnosis only. • If an etiology and its manifestation diagnosis belong to different diagnosis groups, only the greater of the two scores will be awarded. • An etiology/manifestation pair may both be considered for primary diagnosis points when the etiology is in the primary position.

  5. Diagnosis Groups

  6. Diagnosis Groups Awarding of points: Rules with sample diagnosis list: M-itemDiagnosisDiagnosis Group M1021a Malignant melanoma of RLE 3 M1023b Polyneuropathy of neoplastic dz 11 M1023c Critical illness polyneuropathy 11 M1023d LUL lung cancer 3 M1023e Diabetes with skin ulcer 4 M1023f Ulcer limited to skin breakdown 20 M1023g Diabetes with angiopathy 4 • During scoring it is possible to accrue points from more than one diagnosis group per episode, but each diagnosis group can contribute points only once. • In this example, diabetes, neoplasm, and neuropathy diagnoses would only have the possibility to earn points once, but additional points could be earned from the skin ulcer diagnosis group, as well.

  7. Diagnosis Groups Awarding of points: Rules with sample diagnosis list: M-itemDiagnosisDiagnosis Group M1021a Malignant melanoma of RLE 3 M1023b Polyneuropathy of neoplastic dz 11 M1023c Critical illness polyneuropathy 11 M1023d LUL lung cancer 3 M1023e Diabetes with skin ulcer 4 M1023f Ulcer limited to skin breakdown 20 M1023g Diabetes with angiopathy 4 • If a primary and secondary diagnosis fall into the same diagnosis group, points are awarded for the primary diagnosis only. • This rule ensures that, if the diagnosis group qualifies for more points when in the primary diagnosis position versus a secondary diagnosis position, the most points will be awarded for the diagnosis group.

  8. Diagnosis Groups Awarding of points: Rules with sample diagnosis list: M-itemDiagnosisDiagnosis Group M1021a Malignant melanoma of RLE 3 M1023b Polyneuropathy of neoplastic dz 11 M1023c Critical illness polyneuropathy 11 M1023d LUL lung cancer 3 M1023e Diabetes with skin ulcer 4 M1023f Ulcer limited to skin breakdown 20 M1023g Diabetes with angiopathy 4 • When an etiology and manifestation diagnosis earn points in two distinct diagnosis groups, points are awarded only for the diagnosis with the most points. • In this example, malignant melanoma of the RLE is an etiology diagnosis to the manifestation of polyneuropathy in diseases classified elsewhere.

  9. Diagnosis Groups Awarding of points: Rules with sample diagnosis list: M-itemDiagnosisDiagnosis Group M1021a Malignant melanoma of RLE 3 M1023b Polyneuropathy of neoplastic dz 11 M1023c Critical illness polyneuropathy 11 • When an etiology and manifestation diagnosis earn points in two distinct diagnosis groups, points are awarded only for the diagnosis with the most points. • Polyneuropathy in diseases classified elsewhere is designated as a manifestation diagnosis in the ICD-10 code set. • If the melanoma diagnosis would earn more points than the polyneuropathy, the grouper would award points only for the neoplasm. However, points still could be earned in the peripheral neuropathy diagnosis group because of the critical illness polyneuropathy diagnosis. • Likewise, if the polyneuropathy would earn more points than the melanoma, the grouper would award points only for the polyneuropathy and not the cancer.

  10. Diagnosis Groups Awarding of points: Rules with sample diagnosis list: M-itemDiagnosisDiagnosis Group M1021a Malignant melanoma of RLE 3 M1023b Polyneuropathy of neoplastic dz 11 M1023c Critical illness polyneuropathy 11 M1023d LUL lung cancer 3 M1023e Diabetes with skin ulcer 4 M1023f Ulcer limited to skin breakdown 20 M1023g Diabetes with angiopathy 4 • When an etiology and manifestation diagnosis earn points in two distinct diagnosis groups, points are awarded only for the diagnosis with the most points. • IMPORTANT: This does not apply when the manifestation diagnosis is not designated as a manifestation diagnosis per the CMS grouper formula.

  11. Diagnosis Groups Awarding of points: Rules with sample diagnosis list: M-itemDiagnosisDiagnosis Group M1023e Diabetes with skin ulcer 4 M1023f Ulcer limited to skin breakdown 20 • In the ICD-10 code set, non-pressure ulcers are not designated as manifestation diagnoses. • Thus, even though this example indicates that diabetes is the etiology diagnosis responsible for the non-pressure ulcer manifestation diagnosis, and the two diagnoses must be sequenced in the diagnosis list together with the diabetes immediately preceding the ulcer, points could be earned from each of these diagnosis groups because the ulcer diagnosis is not a true manifestation diagnosis per the CMS grouper formula.

  12. M1025 • This M-item was used to help capture case-mix diagnoses replaced by V-codes in the ICD-9 code set. • With the onset of ICD-10, diagnoses may be entered into M1025, but no additional reimbursement is awarded, effectively removing the need to enter diagnosis codes for this M-item. • Diagnoses may be entered into M1025 for the purpose of risk adjustment; however, typically the diagnosis entered into M1025 already would have been entered in either M1011 or M1017 of the OASIS, with risk adjustment captured by one of those two M-item questions.

  13. Primary Point Promotion • The following diagnoses have the potential to earn more points when in the primary diagnosis position versus the secondary diagnosis position: • Diabetes diagnoses • Neuro 1 diagnoses • Brain disorders and paralysis • Skin 1 diagnoses • Trauma wounds • Burns • Post-operative complications • When diagnoses in these diagnosis groups are the first secondary diagnosis (usually behind an Aftercare Z-code), they may be awarded primary diagnosis points.

  14. Severity Scoring • Two categories factor into the severity scoring: • Episode timing • Therapy visit total • Four different scoring equations are possible, shown in Table 1: • Scoring equation 1 = Early episode with < 14 therapy visits • Scoring equation 2 = Early episode with > 13 therapy visits • Scoring equation 3 = Later episode with < 14 therapy visits • Scoring equation 4 = Later episode with > 13 therapy visits

  15. Severity Scoring • The four equations affect points awarded in clinical and functional domains and creation of the HIPPS code. • The four equations are shown in the clinical domain Table 5 and functional domain Table 6.

  16. Clinical Scoring • Four categories factor into the clinical domain score: • Episode timing • Therapy visit total • Diagnoses • Specific M-item responses • 45 variables in which clinical domain points may or may not be awarded

  17. Clinical Scoring • Note how clinical points are no longer earned for diagnoses in the following categories: • Blindness/Low vision • Psych 1 (depression and affective disorders) & Psych 2 (dementias) • Note how: • Blood disorders earn points only in an early episode with > 13 therapy visits • Cancer/neoplasms earn points only when > 13 therapy visits are provided • Diabetes only earns points in the primary diagnosis position when > 13 therapy visits are provided and only as a secondary diagnosis in an early episode with < 14 therapy visits • Gastrointestinal diagnoses earn points only in an early episode of care with > 13 therapy visits when the patient has a bowel ostomy • Pulmonary disorders earn points only in a later episode of care when > 13 therapy visits are provided and when M1860 = 1 or more in an early episode of care when > 13 therapy visits are provided • Pain diagnoses earn points only when < 14 therapy visits are provided • M1200 Vision, M2030 injectable meds, and M1400 dyspnea do not contribute to the clinical domain score

  18. Functional Scoring • Three categories factor into the functional domain score: • Episode timing • Therapy visit total • Answers to OASIS M-items 1810-1860 • Functional scoring is shown in Table 6 and takes into account: • Dressing • Bathing • Toilet transfers • Bed/chair transfers • Ambulation

  19. Functional Scoring • Notice how: • Dressing only has the potential to earn points when < 14 therapy visits are provided • No points are earned for toilet transfers in a later episode of care • Bed/chair transfers earn no points in a later episode of care when > 13 therapy visits are provided • Ambulation earns no points when > 13 therapy visits are provided and M1860 = 1, 2 or 3

  20. Non-Routine Supply (NRS) Scoring • Two categories factor into the NRS scoring: • Diagnoses • Answers to specific OASIS M-item questions • 49 variables from which NRS points may be awarded, shown in Table 8 • If a patient earns NRS points for a diabetic ulcer, points will not be awarded for co-existing non-pressure and non-stasis ulcers (unspecified ulcers)

  21. NRS Scoring • Note how: • Stage 3 and 4 pressure ulcers earn the most NRS points • The number of pressure ulcers present also increases points earned • Diagnoses and conditions that earn 20+ NRS points are: • Primary diagnosis of diabetic ulcer • Primary diagnosis of postoperative complication • Diagnosis of attention to tracheostomy and/or urostomy • Presence of two or more stage 2 pressure ulcers • All stage 3 and 4 pressure ulcer diagnoses • Presence of any number of stage 3 and 4 pressure ulcers • Stasis ulcers with a healing status of early-partial granulation or non-healing • Presence of a bowel ostomy captured in M1630

  22. HIPPS Codes • HIPPS codes are 5-character codes that represent the HHRG and generate the reimbursement for the episode based on data entered into the OASIS. • The five character positions are: • Position #1 – Grouping (episode timing & therapy utilization) • Shown in Table 10

  23. HIPPS Codes • Position #2 – Clinical Severity Level (by total points) • Shown in Table 11

  24. HIPPS Codes • Position #3 – Functional Severity Level (by total points) • Shown in Table 12

  25. HIPPS Codes • Position #4 – Service Utilization Level (therapy visit total) • Shown in Table 13

  26. HIPPS Codes • Position #5 – Severity Group for NRS • Shown in Table 14

  27. Patient Scenario – Severity Scoring Patient admitted for nursing and therapy care due to malignant melanoma of the RLE that has caused polyneuropathy. Co-morbidities include critical illness polyneuropathy, left upper lobe lung cancer, diabetes with a skin ulcer limited to skin breakdown, and diabetic PVD. This is the patient’s first admission for home health and 14 therapy visits are ordered. The patient’s severity scoring is determined by episode timing and the number of therapy visits provided. This patient is new to home care and there are 14 therapy visits ordered, so the severity scoring equation to use is #2 in column 2.

  28. Patient Scenario – HIPPS Grouping The severity score is calculated so that the correct scoring equation can be used in determining points earned in the clinical and functional domains. Similarly, the table for the first character of the HIPPS code for grouping also results in the use of column #2, which has a HIPPS value of 2. Thus, the first character in the patient’s 5-character HIPPS code is 2.

  29. Patient Scenario – Clinical Scoring • To determine the 2nd character in the HIPPS code, the clinical severity level must be calculated. • Remember, four categories factor into the clinical severity score: • Episode timing • Therapy visit total • Diagnoses • Answers to specific M-item questions • First, the score from Table 5, the clinical severity table, must be calculated and then that number entered into the HIPPS code table to determine character #2 of the HIPPS code. • It’s already been determined that the patient has a severity score of 2, now the diagnoses and M-item responses must be reviewed to calculate the clinical score.

  30. Patient Scenario – Clinical Scoring Diagnoses M1021a Malignant melanoma of RLE M1023b Polyneuropathy of neoplastic disease M1023c Critical illness polyneuropathy M1023d LUL lung cancer M1023e Diabetes with skin ulcer M1023f Ulcer limited to skin breakdown M1023g Diabetes with angiopathy M1200 = 2; Vision is severely impaired M1242 = 3; Frequency of pain is daily but not constantly M1620 = 4; Bowel incontinence on a daily basis M1820 = 2; Someone must help the patient put on undergarments, slacks, etc. With this information, Table 5 can be used to calculate the clinical dimension score to be entered into the HIPPS code chart to determine the 2nd HIPPS character, which represents the clinical severity of the patient.

  31. Patient Scenario – Clinical Scoring Let’s look at diagnoses first and calculate the points earned: • Malignant melanoma of the RLE = 5 points • Based on the patient’s severity and known 14 therapy visits, use column two for scoring equation 2 and see row 3 – Primary or Other Diagnosis = Cancer.

  32. Patient Scenario – Clinical Scoring • The next diagnosis is Polyneuropathy of Neoplastic Disease. • This diagnosis codes out to Polyneuropathy in diseases classified elsewhere and it is a case-mix manifestation diagnosis. • Per Table 5, the patient’s known peripheral neurological disorder and score of 2 on M1820 would earn 3 clinical points.

  33. Patient Scenario – Clinical Scoring • However, when an etiology and designated manifestation exist in different diagnosis groups, points are awarded only to the highest scoring group (see slide #10). • Since the malignant melanoma etiology diagnosis earned 5 points and the polyneuropathy in diseases classified elsewhere diagnosis earned only 3 points, points would be awarded only for the neoplasm. • Polyneuropathy in diseases classified elsewhere = 0 points.

  34. Patient Scenario – Clinical Scoring • Critical Illness Polyneuropathy (CIP) = 3 points. • CIP is a form of peripheral neuropathy and even though it shares a diagnosis group with Polyneuropathy in diseases classified elsewhere, since the points could not be awarded for that manifestation diagnosis, they can be awarded for CIP, a different diagnosis in the same diagnosis group.

  35. Patient Scenario – Clinical Scoring • Left upper lobe lung cancer = 0 points. • Per Table 5 this neoplasm diagnosis would earn 5 points. • However, if a primary and secondary diagnosis fall into the same diagnosis group, points are awarded for the primary diagnosis only. • Points already awarded for the malignant melanoma.

  36. Patient Scenario – Clinical Scoring • Diabetes with skin ulcer = 0 points. • For this patient scenario, diabetes is a secondary diagnosis only. • Per Table 5, no points are awarded based on the severity scoring (early episode, > 13 therapy visits).

  37. Patient Scenario – Clinical Scoring • Non-pressure ulcer with skin breakdown only – 17 points • The non-pressure ulcer (manifestation) was caused by diabetes (etiology); however, non-pressure ulcers are not designated manifestation diagnoses for grouper purposes. • Thus, the points earned by the non-pressure ulcer are valid and factor into clinical scoring. • Review of the OASIS revealed M1030 = 4, None of the above – no therapies at home. Points would not have been awarded anyway.

  38. Patient Scenario – Clinical Scoring • Diabetes with angiopathy = 0 points. • Like the diabetes with skin ulcer diagnosis, diabetes does not earn clinical domain points based on the severity scoring. • If points would normally have been awarded for this diagnosis based on the severity scoring, diabetes with angiopathy still would not have earned clinical points because points already would have been awarded to the diabetes with skin ulcer diagnosis code. • Each diagnosis group can contribute points only once per episode.

  39. Patient Scenario – Clinical Scoring Clinical points earned for diagnoses in the clinical domain = 25. Diagnoses M1021a Malignant melanoma of RLE 5 M1023b Polyneuropathy of neoplastic disease 0 M1023c Critical illness polyneuropathy 3 M1023d LUL lung cancer 0 M1023e Diabetes with skin ulcer 0 M1023f Ulcer limited to skin breakdown 17 M1023g Diabetes with angiopathy 0 M1200 = 2; Vision is severely impaired M1242 = 3; Frequency of pain is daily but not constantly M1620 = 4; Bowel incontinence on a daily basis M1820 = 2; Someone must help the patient put on undergarments, slacks, etc. Now it’s time to calculate points earned in the clinical domain solely from M-items.

  40. Patient Scenario – Clinical Scoring M1200 = 2; Vision is severely impaired = 0 points. M1242 = 3; Frequency of pain is daily but not constantly = 0 points. M1620 = 4; Bowel incontinence on a daily basis = 4 points.

  41. Patient Scenario – Clinical Scoring Clinical domain score: Diagnoses M1021a Malignant melanoma of RLE 5 M1023b Polyneuropathy of neoplastic disease 0 M1023c Critical illness polyneuropathy 3 M1023d LUL lung cancer 0 M1023e Diabetes with skin ulcer 0 M1023f Ulcer limited to skin breakdown 17 M1023g Diabetes with angiopathy 0 M1200 = 2; Vision is severely impaired 0 M1242 = 3; Frequency of pain is daily but not constantly 0 M1620 = 4; Bowel incontinence on a daily basis 4 M1820 = 2; Someone must help the patient with dressing NA (points may be awarded in functional scoring) TOTAL CLINICAL DOMAIN POINTS EARNED: 29

  42. Patient Scenario – HIPPS Clinical Review thus far: Severity scoring – Scoring equation #2 HIPPS character #1 = 2 Clinical domain score = 29 HIPPS character #2 = C HIPPS Code = 2Cxxx CFS score = C3FxSx x = yet unknown CFS = Clinical, functional, service scores – per Projected V. Actual Report

  43. Patient Scenario – Functional Scoring • The third character in the HIPPS code for payment captures the functional severity of the patient. • Remember, the functional domain has three categories that factor into points awarded: • Episode timing • Therapy visit total • Answers to OASIS M-item questions 1810-1860 • Severity score is already known and scoring equation 2 is used to calculate the points in Table 6 for the functional domain. • Let’s look now and see how many points are earned based on the patient’s level of function at time of the SOC assessment.

  44. Patient Scenario – Functional Scoring M1810 = 1, patient able to dress upper body if clothes laid out 0 M1820 = 2, patient requires help to dress lower body 0 M1830 = 1, with the use of devices can shower safely 0 M1840 = 1, requires assist to get to and from and on/off toilet 0 M1850 = 2, able to bear weight and pivot but cannot transfer self 1 M1860 = 3, requires constant supervision or assist for safe ambulation 0 TOTAL FUNCTIONAL DOMAIN POINTS EARNED = 1

  45. Patient Scenario – HIPPS Functional Review: Severity scoring – Scoring equation #2 HIPPS character #1 = 2 Clinical domain score = 29 HIPPS character #2 = C Functional domain score = 1 HIPPS character #3 = F HIPPS Code = 2CFxx CFS score = C3F1Sx x = yet unknown CFS = Clinical, functional, service scores – per Projected V. Actual Report

  46. Patient Scenario – Service Utilization Scoring • Service utilization is based solely on the number of therapy visits provided. However, the HIPPS score is still calculated using the patient’s severity score. • This patient’s severity score is 2 and thus, scoring equation 2 is used when determining the service utilization HIPPS character #4. • The service utilization level HIPPS score is K. • See how it’s possible to provide numerous therapy visits and still have a low service utilization score? • Accurate OASIS data collection is imperative, but low scores can still occur due to the way in which the algorithm calculates the data.

  47. Patient Scenario – HIPPS Service Utilization Review: Severity scoring – Scoring equation #2 HIPPS character #1 = 2 Clinical domain score = 29 HIPPS character #2 = C Functional domain score = 1 HIPPS character #3 = F Service utilization domain HIPPS character #4 = K HIPPS Code = 2CFKx CFS score = C3F1S1 x = yet unknown CFS = Clinical, functional, service scores – per Projected V. Actual Report

  48. Patient Scenario – NRS Scoring The fifth character in the HIPPS code is represented by NRS points. For this patient scenario, based on review of the OASIS, the following NRS points will be awarded: Non-pressure ulcer = 13 points OASIS M1620 = 4; bowel incontinence on a daily basis = 10 points TOTAL NRS POINTS EARNED = 23

  49. Patient Scenario – HIPPS NRS • Based on the 23 total NRS points earned, and assuming the agency will provide and bill for non-routine supplies related to the bowel incontinence, the fifth and final character for the HIPPS code is U. • Should an agency not document billing for use of NRS related to bowel incontinence, the fifth character of the HIPPS code would be changed to the number 3, which would decrease reimbursement for the episode of care.

  50. Patient Scenario – Final Review Final Review: Severity scoring – Scoring equation #2 HIPPS character #1 = 2 Clinical domain score = 29 HIPPS character #2 = C Functional domain score = 1 HIPPS character #3 = F Service utilization domain HIPPS character #4 = K NRS points score = 23 HIPPS character #5 = U HIPPS Code = 2CFKU CFS score = C3F1S1 CFS = Clinical, functional, service scores – per Projected V. Actual Report

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