HIPPS and Rate Codes for SNF and HHA Claims Required/ Keeping Accurate Documentation and Coding - Critical to Patient Care

Date Issued: 4/4/2014

CMS Requires HIPPS and Rate Codes for Skilled Nursing Facilities and Home Health Agencies Claims — Effective July 1, 2014

As mandated by the Centers for Medicare & Medicaid Services (CMS), beginning July 1, 2014, skilled nursing facilities and home health agencies must include all applicable Health Insurance Prospective Payment System (HIPPS) and rate codes for claims involved in Risk Adjustment Processing System (RAPS) reporting.

These codes, specifically Resource Utilization Groups (RUGs) and Home Health Resources Groups (HHRGs) identify and represent specific sets of patient characteristics (or case-mix groups). CMS uses this information for payment determination.

For EmblemHealth, this information impacts Medicare reimbursement via the RAPS reporting (CMS Encounter Data System) process. If HIPPS codes are not included in the claims submissions, the claim will be denied.

Complete and Accurate Medical Record Documentation and Coding Critical to Patient Care

Clear and complete clinical documentation is the foundation of every patient's health record. It significantly impacts patient care, coordination, coding, billing and compliance. It is also:

  • The key determinant of the quality of care a patient received
  • The primary tool for clinicians to communicate about a patient
  • Evidence that the care billed for was rendered to the patient
  • Data we rely on for strategic planning, internal research and identification of case, care or disease management opportunities

Accurate coding translates your clinical documentation into uniform diagnostic and procedural data sets. The better the documentation, the more we can help ensure the best outcomes for your patients — our members.

For more information, view the Centers for Medicare & Medicaid Services' Evaluation and Management Services Guide.