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• Narrative Content

CodeSystem: Health Insurance Prospective Payment System (HIPPS)

Official URL: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ProspMedicareFeeSvcPmtGen/HIPPSCodes				Version: 2.0.0-ballot
Active as of 2022-02-18				Computable Name: CMSHIPPSCodes
Copyright/Legal: CMS maintains HIPPS. There are no known constraints on the use of HIPPS. See more information about HIPPS codes here

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. Case-mix groups are developed based on research into utilization patterns among various provider types. For the payment systems that use HIPPS codes, clinical assessment data is the basic input. A standard patient assessment instrument is interpreted by case-mix grouping software algorithms, which assign the case mix group. For payment purposes, at least one HIPPS code is defined to represent each case-mix group. These HIPPS codes are reported on claims to insurers. Institutional providers use HIPPS codes on claims in association with special revenue codes. One revenue code is defined for each prospective payment system that requires HIPPS codes. HIPPS codes are placed in data element SV202 on the electronic 837 institutional claims transaction, using an HP qualifier, or in Form Locator (FL) 44 (“HCPCS/rate”) on a paper UB-04 claims form. The associated revenue code is placed in data element SV201 or in FL 42. In certain circumstances, multiple HIPPS codes may appear on separate lines of a single claim.

HIPPS codes are alpha-numeric codes of five digits. Each code contains intelligence, with certain positions of the code indicating the case mix group itself, and other positions providing additional information. The additional information varies among HIPPS codes pertaining to different payment systems, but often provides information about the clinical assessment used to arrive at the code. Which positions of the code carry the case mix group information may also vary by payment systems.

This Code system is referenced in the content logical definition of the following value sets:

• PDexPAInstitutionalProcedureCodes
• PDexPriorAuthInstitutionalProcedureCodes