For those who need to learn and understand about PDPM, they often find themselves asking, what is HIPPS? HIPPS stands for Health Insurance Prospective Payment System. A Prospective Payment System is a reimbursement method used by the CMS for Medicare payments, in which payments are made based on a pre-determined fixed amount for services provided to patients or residents.
HIPPS codes represent specific sets of patient or resident characteristics (case-mix groups) health insurers use to make payment determinations for prospective payment systems. For Skilled Nursing Facilities (SNFs), HIPPS codes are used to calculate PDPM rates—a process that can be made drastically easier with the use of effective long-term care software.
One easy way to ensure that you are getting accurate PDPM rates is to use a HIPPS Projector tool, which gives you an idea of what your score will look like before you conduct the formal MDS assessment.
HIPPS Code Examples
A HIPPS code is used by insurers to determine payments for services provided to residents in an SNF. But in addition to asking what is HIPPS, you will still need to know the five case-mix adjusted components under PDPM. They are:
- PT (Physical Therapy) – uses the clinical category (Major Joint Replacement or Spinal Surgery, Non-Orthopedic Surgery & Acute Neurologic) and functional score as the basis for patient/resident classification
- OT (Occupational Therapy) – uses the clinical category and functional score as the basis for patient/resident classification
- SLP (Speech-Language Pathology) – classification is determined by the presence of an acute neurologic condition, SLP-related comorbidity, cognitive impairment, mechanically-altered diet or a swallowing disorder
- NTA (Non-therapy Ancillary) groups – NTA Comorbidity Score determines the patient/resident classification
- Nursing – has the same characteristics as under RUG-IV
If you want to better understand what is HIPPS, you will also need to understand the PDPM HIPPS Coding Crosswalk and the PDPM HIPPS Coding Table.
The following table describes how PDPM HIPPS codes are derived for PT, OT, SLP, and NTA groups:
The first, second, and fourth positions of the code use this table to translate PT/OT, SLP, NTA Payment Groups into code values:
|PT/OT Payment Group||SLP Payment Group||NTA Payment Group||HIPPS Character|
PDPM HIPPS Coding Crosswalk: Nursing Component
|Nursing Payment Group||HIPPS Character||Nursing Payment Group||HIPPS Character|
PDPM HIPPS Coding Table: Assessment Indicator
|HIPPS Character||Assessment Type|
|0||IPA (interim payment assessment)|
|6||OBRA Assessment (not coded as a PPS Assessment)|
The above table helps answer the question of what is HIPPS and links the possible assessment indicators in the last character of the HIPPS code with the PPS assessments that would prompt that character. Part A PPS Discharge assessment isn’t a payment assessment under PDPM.
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The Difference Between PDPM HIPPS Codes and RUG-IV Classifications
In order to better understand HIPPS codes, it is essential to discuss the differences between PDPM and RUG-IV. RUG-IV was a patient and resident classification system used previously by the federal government to reimburse SNFs for services provided to their patients and residents.
- A stronger focus on the quality of care provided, rather than the quantity of care services provided.
- Additional resources (coding crosswalks and classification logic) to target vulnerable populations
- More focus on specific areas of MDS assessments during resident admissions
- Reduction of administrative duties to ease the burden of documentation requirements for SNFs
So, what is HIPPS, how does it factor into PDPM, and what is the HIPPS code list? A HIPPS code is the formula for payment in PDPM. A HIPPS code is made up of five case-mix adjusted components (PT, OT, SLP, Nursing, and Non-therapy ancillaries). This is unlike RUG-IV, which was made up of eight major classification systems that are:
- Rehabilitation Plus Extensive Services,
- Rehabilitation, Extensive Services,
- Special Care High
- Special Care Low
- Clinically Complex
- Behavioral Symptoms
- Cognitive Performance Problems
- Reduced Physical Function
Above, we provided a HIPPS code example, to help with understanding HIPPS.
So, What Is HIPPS, and Why Is It Important?
To answer the question of what is HIPPS? HIPPS codes represent specific sets of patient or resident characteristics (case-mix groups) health insurers use to make payment determinations on prospective payment systems. HIPPS codes are important as they are used when making claims for services provided to residents in an SNF. These healthcare services and their details can be stored in care plan software.
Administrators need to ensure that when they are making a claim, the HIPPS rate matches that of the assessment that was sent and accepted by the state in which the long-term care facility operates.
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