Patient-Driven Payment Model (PDPM)

The Patient-Drive Payment Model (PDPM) is here, and AANAC will continue to help you through the transition. Visit this page frequently for new tools, education, and resources for ongoing success under PDPM.

PDPM HIPPS Codes: How They Will Be Determined

Posted By: Caralyn Davis, Staff Writer
Post Date: 04/10/2019

When the Patient-Driven Payment Model (PDPM) implements as the case-mix classification system for the skilled nursing facility prospective payment system (SNF PPS) on Oct. 1, 2019, SNFs will have to code a new set of health insurance prospective payment system (HIPPS) codes in MDS item Z0100A (Medicare Part A HIPPS code) and on the Part A claim to identify a SNF resident’s payment classification, pointed out officials with the Centers for Medicare & Medicaid Services (CMS) during the Dec. 11 SNF PPS: PDPM National Provider Call. Note: Access the call slides, as well as a transcript and recording, here.

 

The RUG-IV system uses a 5-character HIPPS code. “The first three characters represent the patient’s RUG classification, while the last two characters represent the assessment used to classify the patient,” said officials.

 

PDPM also will use a five-character HIPPS code. However, instead of classifying into a single payment group like in RUG-IV, patients will classify into a payment group under each of the five PDPM case-mix-adjusted components: physical therapy (PT), occupational therapy (OT), speech-language pathology (SLP), nursing, and non-therapy ancillary (NTA), said officials.

 

So PDPM uses a different algorithm in terms of what each of the five characters represents. “The first character represents the patient’s PT and OT payment group; the second, his or her SLP payment group; the third, his or her nursing payment group; the fourth, his or her NTA payment group; and finally, the fifth, the assessment used to classify the patient,” explained officials.

 

Note: PT and OT use the same classification criteria, so they end up having the same payment group, which is why they can share one character of the HIPPS code. However, the PT and OT components use different base rates and case-mix indexes (CMIs), and each case-mix-adjusted per-diem component rate is calculated independently, explained officials. For example, a patient who classifies into the TC case-mix group for PT will also classify into the TC case-mix group for OT. But the TC will pay differently in PT than it does in OT due to the different base rates and CMIs.

 

CMS has developed three crosswalks to guide SNFs through HIPPS code creation:

  • A crosswalk for the PT, OT, and NTA payment groups;

  • A crosswalk for the nursing payment group; and

  • A crosswalk for the PPS assessment.

 

The following crosswalks are adapted from slides 79 – 81 and slide 83:

 

PDPM HIPPS Coding Crosswalk: PT, OT, NTA Components

PT/OT Payment Group

SLP Payment Group

NTA Payment Group

HIPPS Character

TA

SA*

NA

A

TB

SB

NB

B

TC

SC

NC

C

TD

SD

ND

D

TE

SE

NE

E

TF

SF

NF*

F

TG

SG

 

G

TH

SH

 

H

TI

SI

 

I

TJ

SJ

 

J

TK

SK

 

K

TL

SL

 

L

TM

 

 

M

TN

 

 

N

TO

 

 

O

TP*

 

 

P

* Providers may sometimes need to bill the default code instead of a crosswalked HIPPS code (e.g., when a PPS MDS is considered late). Billing the default code, which will be ZZZZZ under PDPM, is the equivalent of billing (1) the TP payment group for PT and OT, (2) the SA payment group for SLP, and (3) the NF payment group for NTA because these groups represent the lowest possible per-diem rates.

 

The above crosswalk links each of the PT/OT, SLP, and NTA payment groups with:

  • The first character in the HIPPS code to represent the PT/OT payment group;

  • The second character in the HIPPS code to represent the SLP payment group; and

  • The fourth character in the HIPPS code to represent the NTA payment group.

 

“For example, if the patient qualified for the PT and OT group TA, then the first character in the HIPPS code, which represents the patient’s PT and OT classification, would be an A,” explained officials.

 

PDPM HIPPS Coding Crosswalk: Nursing Component

Nursing Payment Group

HIPPS Character

Nursing Payment Group

HIPPS Character

ES3

A

CBC2

N

ES2

B

CA2

O

ES1

C

CBC1

P

HDE2

D

CA1

Q

HDE1

E

BAB2

R

HBC2

F

BAB1

S

HBC1

G

PDE2

T

LDE2

H

PDE1

U

LDE1

I

PBC2

V

LBC2

J

PA2

W

LBC1

K

PBC1

X

CDE2

L

PA1*

Y

CDE1

M

 

 

* Providers may sometimes need to bill the default code (e.g., when a PPS MDS is considered late) instead of a crosswalked HIPPS code. Billing the default code, which will be ZZZZZ under PDPM, is the equivalent of billing the PA1 payment group for nursing (i.e., the lowest possible per-diem rate).

 

The above crosswalk links the nursing payment group to the third character in the HIPPS code. “For example, if the patient qualified for the group CA1, then the third character in the HIPPS code, which represents the nursing group, would be a Q,” said officials.

 

Note: The original PDPM slide set posted on the PDPM website listed character 3 as NTA and character 4 as nursing. That appears to have been a mistake. Not only do the newer call slides and the comments from CMS officials cite character 3 as nursing and character 4 as NTA, but that order is consistent with the order in the CMG to HIPPS Code Mapping document in the file. PDPM GROUPER Logic (SAS).

 

PDPM HIPPS Coding Crosswalk: Assessment Indicator

HIPPS Character

Assessment Type

0

IPA (interim payment assessment)

1

PPS 5-day

6

OBRA Assessment (not coded as a PPS Assessment)

 

The above crosswalk links the possible assessment indicators in the last character of the HIPPS code with the PPS assessments that would prompt that character. Note: Remember that the Part A PPS Discharge assessment isn’t a payment assessment under PDPM.

 

“Taken together these five characters will provide all of the payment classification information necessary to bill for a given patient,” said officials.

 

The following chart takes two examples of patient classification scenarios and graphically illustrates the construction of the HIPPS codes that would be used to represent these scenarios on a claim.

 

 


For permission to use or reproduce this article in full or in part, please complete a permissions form.



Meet the volunteers who review LTC Leader articles and FAQ content. They represent the best and brightest minds in LTC, and we thank them.

 

Categories:

Comments:
Add New Comment
Name*:  
Email*:  
Website:
Title*:  
Comment*: