June 8, 2017
Clarification on Health Insurance Prospective Payment System (HIPPS) Coding Changes
Change Request 9585 revised CMS Publication 100-04, Ch. 10 by adding Section 10.1.19.3 which explains that the Fiscal Intermediary Standard System (FISS) compares the provider-submitted HIPPS code (revenue code 0023) with the HIPPS code calculated based on the assessment information in the quality system. If the codes do not match, the OASIS-calculated HIPPS code is used for payment.
As a reminder, when the OASIS HIPPS code is billed with a 1 (early episode) and the number of therapy visits fall between 0-13, the claim may recode the 4th position based on the number of therapy visits billed. When this occurs and the 1st position of the HIPPS code remains a 1 (the same as the recoded HIPPS), the only position that will recode is the 4th. This also applies to HIPPS codes that begin with a 2, 3 and 4. However, the only exception when HIPPS code will not recode is when it begins with a 5 and has 20+ therapy visits billed.
If the HIPPS code is a 1 and is recoded to a 2, 3, or 4, the treatment authorization code was used to recode the entire HIPPS code. This also applies if the HIPPS code is billed with a 2, 3, or 4 and the 1st position changes.
Refer to the recoding of claims based on episode sequence and therapy thresholds information under Section 70.4 in Pub. 100-04, Ch. 10 for additional information.