Learn the language: PPS term/acronym reference
Learn the language: PPS term/acronym reference
This reference guide from the Health Care Financing Administration (HCFA) lists terms and acronyms that will be used for line items on UB-92 home health (HH) claims after the prospective payment system (PPS) goes into effect Oct. 1. (See the PPS summary, p. 88.)
• DME — durable medical equipment.
Billed by revenue codes and/or HCPCS. Paid by HCFA according to a HCFA DME fee schedule accessible on the HCFA Web site (www.hcfa.gov/ stats/pufiles.htm). Note subsequent law (BBRA 99) removed DME from HH PPS consolidated billing — suppliers can still bill DMERCs directly (supersedes Proposed Rule).
• DMERC — DME regional carrier.
Four Medicare carriers nationally processing claims for DME on HCFA 1500 claims.
• Episode.
The home health prospective payment unit of payment will be a 60-day episode.
In general, episodes are expected to be distinct (not overlapping) and contiguous in time for cases of continuous care (one ending on one day, the next starting the very next day even if no services are provided that next day).
• FC — final claim.
Second of two "bookend claims" at opening and closing of HH PPS episode to receive one of two split percentage payments.
• HCPCS — HCFA common procedural coding system.
Coding for services or items used on the UB-92 in FL 44 or HCFA 1500 claim forms. A list of HCPCS is accessible on the HCFA Web site (www.hcfa.gov/stats/pufiles.htm).
• HHA(s).
Home health agency(s).
• (H)HRG — home health resource group.
A group to which a home health patient is classified. The group is based on the information about the patient’s clinical resource needs as reported on the patient’s Outcome and Assessment Information Set (OASIS) assessment(s). OASIS items describing the patient’s condition, as well as the expected therapy needs (physical, speech-language pathology, or occupational) are used to determine the case-mix adjustment to the standard payment rate. One of 80 HH episode payment rates.
• HIPPS code — health insurance prospective payment system.
Procedural coding used in FL 44 of UB-92 in association with certain HCFA prospective payment systems (skilled nursing facility, home health). HIPPS will be assigned to HHRGs for HH PPS. The code that is generated when the OASIS assessment information is fed into the grouper logic at the HHA. The HIPPS code corresponds to the appropriate case-mix category.
• IC — initial claim.
First of two "bookend claims" at opening and closing of HH PPS episode to receive one of two split percentage payments.
• Line item.
Service- or item-specific detail of claim. Contains repeated entries of FLs 42-49 on UB-92.
• LUPA — low utilization payment adjustment.
An episode of four or fewer visits paid by national standardized per visit rates instead of HHRGs.
• MSA — metropolitan statistical area.
Each HHA’s labor market area is determined based on definitions of MSAs. This is used to calculate the wage-index adjustments to the 60-day episode payments. The MSA used is determined by the patient’s residence.
• National standard per visit rates.
National rates for each of six home health disciplines, based on historical claims data. Used in payment of LUPAs and calculation of outliers.
• Outlier.
An addition to a full episode payment in cases where costs of services delivered are estimated to exceed a fixed loss threshold. HH PPS outliers are computed as part of Medicare claims payment by Pricer software.
• PEP (or PEPA) — partial episode payment (or partial episode payment adjustment).
A reduced episode payment that may be made based on the number of service days in an episode (always fewer than 60 days, employed in cases of transfers or discharges with readmissions).
A proportional payment adjusting the original 60-day episode payment to reflect the length of time the beneficiary remained under the agency’s care prior to one of the following events: A beneficiary elected transfer to a new HHA that is not under common ownership with the original HHA, or a beneficiary was discharged because the goals in the plan of care were met and returned to the same HHA during the 60-day episode.
• POC — plan of care.
Medicare HH services for the homebound beneficiaries must be delivered under a plan established by a physician.
• P/O(s).
Prosthetics and orthotics
• PPS — prospective payment system.
Medicare payment for medical care based on pre-determined payment rates or periods, linked to the anticipated intensity of services delivered and/or beneficiary condition.
• Pricer.
Software modules in Medicare claims processing systems, specific to certain benefits, used in pricing claims, most often under prospective payment systems.
• Revenue code.
Payment codes for services or items placed in FL 42 of the UB-92 found in Medicare and/or NUBC (National Uniform Billing Committee) manuals (42x, 43x, etc.).
Note that a new revenue code 0023 will be used on a distinct line item when billing episode payments (HIPPS in HCPCS field, separate line items for visits and supplies follow on FC), and an "x" in the last digit of numeric three-digit revenue codes means that value can vary from 0-9. HCFA manuals can be found on the Web site (www.hcfa. gov/pubforms/p2192toc.htm).
• RHHI — regional home health intermediaries.
Five fiscal intermediaries nationally designated to process Medicare home health and hospice claims.
• SCIC — significant change in condition (adjustment).
When changes in patient condition dictate, a single episode may be paid under multiple HHRGs, the amount for each HHRG prorated to the number of service days delivered under that HHRG, and all the prorated amounts added for the final episode payment.
• SCIC — significant change in condition.
HHRGs can be changed mid-episode when a beneficiary experiences a significant change in condition during a 60-day episode. In order to receive a new case-mix assignment (HHRG) for purposes of SCIC payment during the 60-day episode, the HHA must complete an OASIS assessment and obtain the necessary physician change orders showing the significant change in treatment approach.
• TOB — type of bill (i.e., 32x, 33x, 34x).
Coding representing the nature of each UB-92 claim (i.e., type of benefit, such as homebound home health; payment source, such as specific Medicare trust fund; and frequency of bill, such as initial or cancellation) — an "x" in the last digit of numeric three-digit revenue codes means that value can vary from 0-9. These codes are found in Medicare and/or NUBC (National Uniform Billing Committee) manuals. HCFA manuals can be found on the Web site (www.hcfa.gov/ pubforms/p2192 toc.htm).
• UB-92.
The claim or bill form, in either paper or electronic version, used by most institutional health care providers.
Published by HCFA as the UB-92 Form 1450, but the standard itself is maintained by a nongovernmental body: the National Uniform Billing Committee, an entity under the American Hospital Association in Chicago.
• 10/01/00.
Legislated effective date for HH PPS.
• 1500.
The claim form, in either paper or electronic version (NSF), used by most non-institutional health care providers and suppliers to bill Medicare. Published by HCFA as the Form 1500.
• 485.
HCFA form number for POC.
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