Select Page

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 an effective long term care software.

HIPPS Code Examples

Physical therapy session for a nursing home resident, which will then be document using a HIPPS code.
PT (Physical Therapy)is one of the five case-mix adjusted components under PDPM.

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 GroupSLP Payment GroupNTA Payment GroupHIPPS Character
TASA*NAA
TBSBNBB
TCSCNCC
TDSDNDD
TESENEE
TFSFNF*F
TGSG G
THSH H
TISI I
TJSJ J
TKSK K
TLSL L
TM  M
TN  N
TO  O
TP*  P

PDPM HIPPS Coding Crosswalk: Nursing Component

Nursing Payment GroupHIPPS CharacterNursing Payment GroupHIPPS Character
ES3ACBC2N
ES2BCA2O
ES1CCBC1P
HDE2DCA1Q
HDE1EBAB2R
HBC2FBAB1S
HBC1GPDE2T
LDE2HPDE1U
LDE1IPBC2V
LBC2JPA2W
LBC1KPBC1X
CDE2LPA1*Y
CDE1M  

PDPM HIPPS Coding Table: Assessment Indicator

HIPPS CharacterAssessment Type
0IPA (interim payment assessment)
1PPS 5-day
6OBRA 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.

Contact us here if you would like to test drive our user-friendly long term care software.

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.

PDPM came into effect on October 1, 2019, as a replacement for RUG-IV. As for the CMS’ primary goals of moving to PDPM, they include:

What is HIPPS? This infographic shows a HIPPS Code Classification Build Example.
HIPPS code classification build example.
  • 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:

  1. Rehabilitation Plus Extensive Services,
  2. Rehabilitation, Extensive Services,
  3. Special Care High
  4. Special Care Low
  5. Clinically Complex
  6. Behavioral Symptoms
  7. Cognitive Performance Problems
  8. Reduced Physical Function

Above, we provided a HIPPS code example, to help with understanding HIPPS.

So, What Is HIPPS, and Why Is It Important?

Two elderly women outdoors in the sun. HIPPS codes document resident characteristics.
HIPPS codes represent specific sets of resident characteristics health insurers use to make payment determinations on prospective payment systems.

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 a 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.

For more on recent trends in long term care, read our blog and subscribe to the LTC Heroes podcast.

Elijah Oling Wanga
Latest posts by Elijah Oling Wanga (see all)