Z0100A. Medicare Part A: HIPPS code

Step-by-Step Coding Guide for Item Set Z0100A: Medicare Part A: HIPPS Code

1. Review of Medical Records

• Begin with a comprehensive review of the resident's medical and therapy records, especially focusing on recent assessments and care plans.
• Note any changes in the resident's condition or treatment that might affect the HIPPS code calculation.

2. Understanding Definitions

• HIPPS (Health Insurance Prospective Payment System) Code: A code used in the Medicare system to classify a resident's resource utilization that determines the reimbursement rate for that resident under Medicare Part A. It is derived from the data collected in the MDS assessment.

3. Coding Instructions

• Enter the five-character HIPPS code that correctly reflects the classification calculated from the latest MDS assessment.
• Use the RUG-IV grouper software or equivalent to generate the HIPPS code based on the MDS data.

4. Coding Tips

• Ensure that the MDS assessment is fully and accurately completed, as this data directly influences the HIPPS code calculation.
• Regularly update training for staff involved in MDS assessments to ensure accurate data collection and HIPPS code generation.

5. Documentation

• Document the process for generating the HIPPS code, including the version of the software used, the date of the MDS assessment, and the specific sections of the MDS that influenced the HIPPS code.
• Keep a record of any communications with Medicare or other third-party auditors regarding the HIPPS code and its justification.

6. Common Errors to Avoid

• Using outdated RUG-IV grouper software or incorrect MDS versions which can lead to incorrect HIPPS codes.
• Failing to update the HIPPS code when a significant change in the resident's condition occurs that would alter their classification.
• Incorrectly entering data into the MDS that directly affects the HIPPS code, such as therapy minutes or ADL scores.

7. Practical Application

• Example: A resident who has undergone hip replacement surgery participates in significant amounts of therapy and has moderate to severe clinical needs. The completed MDS assessment data is input into the RUG-IV grouper, which calculates a HIPPS code of "RBXH2." This code indicates a Rehab Ultra High category, with a therapy indication and a second character clinical category reflecting higher clinical severity. The coding staff ensures this HIPPS code is entered into Z0100A on the MDS and used in billing to Medicare.

Please note that the information provided in this guide for MDS 3.0 Item set Z0100A was originally based on the CMS's RAI Version 3.0 Manual, October 2023 edition. Every effort will be made to update it to the most current version. The MDS 3.0 Manual is typically updated every October. If there are no changes to the Item Set, there will be no changes to this guide. This guidance is intended to assist healthcare professionals, particularly new nurses or MDS coordinators, in understanding and applying the correct coding procedures for this specific item within MDS 3.0. 

The guide is not a substitute for professional judgment or the facility’s policies. It is crucial to stay updated with any changes or updates in the MDS 3.0 manual or relevant CMS regulations. The guide does not cover all potential scenarios and should not be used as a sole resource for MDS 3.0 coding. 

Additionally, this guide refrains from handling personal patient data and does not provide medical or legal advice. Users are responsible for ensuring compliance with all applicable laws and regulations in their respective practices.