How Do You Read a HIPPS Code?

by Keith Grunig

Stressed administator

What does a HIPPS Code Stand For?

The US Government is one of the best at using anacronyms.  Aside from the military, CMS has its own complicated anacronym language.  I keep learning new ones or having to refer to what a certain anacronym means.  Here are just a few:  OASIS, PDGM, HIPPS, CMS, HHA, HHRG, BIMS, UPIC, ZPIC, and ADR to name a few.  Those who are new to the industry can become understandably confused and overwhelmed. 

HIPPS means Health Insurance Prospective Payment System.  CMS says "Health Insurance Prospective Payment System (HIPPS) rate codes represent specific sets of patient characteristics (or case-mix groups) health insurers use to make payment determinations under several prospective payment systems."

How do you read a HIPPS Code?

If you want to feel like you're reading a foreign language, look at a HIPPS Code.  A HIPPS Code in home health using a code structure that describes the clinical grouping a patient is in.  Once you understand the code structure you can learn about the patient pretty easily.   The first postion is information is the Referral Source and Timing.  The options are Institutional and Community for referral source and Early and Late for episode timing.  There are 4 options.  1- Community Early, 2- Institutional Early, 3- Community Late, 4- Institutional Late.  Position 2 is the clinical grouping.  There are 12 options lettered A-L.  To learn about the 12 clinical groups click here.  Position #3 is Functional Level.  There are 3 options.  A- Low, B- Medium, C- High.  Position #4 is for comorbidity.  There are three options.  1- None, 2- Low, 3- High.  The Fifth Position is a placeholder and doesnt mean anytihng.  It will always stay a 1.  

CMS has a handy decoder on this link here.  

So, using this matrix, we can easily decipher any patient in home health and understand a little bit about the patient.  Each patient with PDGM will have 2 HIPPS codes, one for the first 30 days and another for the second 30 days.  

Here are a few examples.  These are from Home Care Answers reporting- notice the difference between HIPPS Codes.  The top line is what the HIPPS code would be before Home Care Answeres audited the chart, and the second one is after.  There are differences- which reflect accuracy, and usually reflect increased reimbursement.

Home Health HIPPS Codes


The first one is 2KA11.  What does it say?  Position 1 Referral source and timing.  2 is for Instutional Early. Second Position Clinical Grouping. K is for the clinical grouping from PDGM (MMTA Infectious Disease).  3rd Position is Functional Level.  A is for low.  4th Position is for Comorbidity adjustment- 1, meaning low.  The patient has at least 1 comorbidity that increases reimbursement.  


The second one is 2KC21.  Notice the change in the third position- functional impairement.  After our review, we found that several ADLs were incorrectly scored too low given what the patient had.  We suggested higher scoring in ADLs and that increased the functional impairement to C- High.  


The Second 30 Days shows 2KA11 for the top line.  First position is 3, meaning Community Late.  Institutional referrals only stay institutional for the first 30 days.  Also, the episode timing is only early for the first 30 days.  


There you have it.  You can now read any HIPPS code for Home Health.  Home Care Answers will help increase accuracy and reimbursement to sure the proper HIPPS codes are transferred to CMS.  Find out how we can help. 


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