Nov. 4, 2019

Medicare Advantage Organizations (MAOs) are required to submit Submission of Health Insurance Prospective Payment System (HIPPS) codes on skilled nursing facility (SNF) and home health (HH) encounters submitted with “from” dates of service as of July 1, 2014 or later. Specifically, HIPPS codes for SNF and HH encounters should come from the initial Omnibus Budget Reconciliation Act (OBRA) required comprehensive assessment (Admission assessment) and Outcome and Assessment Information Set (Start of Care assessment), respectively.

Medicare Fee-for-Service (FFS) is introducing new payment methodologies for HH and SNF services. For FFS SNF and HH providers, the SNF Patient Driven Payment Model (PDPM) was effective Oct. 1, 2019 and the HH Patient Driven Groupings Model (PDGM) will be effective Jan. 1, 2020. These new payment models introduce new HIPPS code sets for HH and SNF services.

CMS updated the HIPPS code sets used in the Encounter Data System (EDS) to incorporate the new HIPPS code sets. In order to allow providers and MAOs maximum flexibility in the submission of HIPPS codes on encounter data, CMS will accept the existing HIPPS codes as well as the new HIPPS codes.

SNF encounters with “from” dates on or after Oct. 1, 2019 and HH encounters with “from” dates of service on or after Jan. 1, 2020 may be submitted using the existing HIPPS codes or the new HIPPS codes.

• SNF encounters with “from” dates of service prior to Oct. 1, 2019 should continue to be submitted with previously existing HIPPS codes.
• HH encounters with “from” dates of service prior to Jan. 1, 2020 should continue to be submitted with existing HIPPS codes.
• For SNF stays lasting 14 days or less in which an Admission assessment was not completed prior to discharge, MAOs should follow the guidance outlined in the Dec. 4, 2014 HPMS memorandum with the subject line: “Additional Guidance Regarding Submission of Health Insurance Prospective Payment System (HIPPS) Codes to Encounter Data System.” As noted in that memo, MAOs may submit the HIPPS code from another assessment that took place during the stay or submit a default HIPPS code.
• The default HIPPS code for encounters with a “from” date of service prior to Oct. 1, 2019 is “AAA00.” The default HIPPS code for encounters with a “from” date of service on or after Oct. 1, 2019 is “ZZZZZ.”

Please send any questions related to this guidance to Provider.Education@bcbssc.com and specify “Updated Information on Submission of Health Insurance Prospective Payment System (HIPPS) Codes to Medicare Advantage Encounter Data System – September 2019” in the subject line. Thank you.