Palmetto GBA recently released the two HIPPS codes being targeted in a specific ADR (Additional Documentation Request) probe review. The targeted HIPPS codes were selected from a list of top 20 home health HIPPS codes, the the codes with the highest number of denials from this list These HIPPS codes are “2CGK* and 1BGP* (variable last digit of HIPPS Codes).”[i]
“These edits will be set for four regions within the J11 Home Health and Hospice jurisdiction.
These four regions are:
- Midwest (Illinois, Indiana and Ohio)
- Southeast (Kentucky, North Carolina, South Carolina and Tennessee)
- Southwest (Arkansas, Louisiana, New Mexico, Oklahoma and Texas)
- Gulf Coast (Alabama, Florida, Georgia and Mississippi)”[ii]
HIPPS codes are generated by HHRG scores which are generated from OASIS answers in the episode type, M; the clinical domain, the functional domain, and the service utilization domain. Let’s look at how the HIPPS score 2CGK is generated:
Position #1 of the HIPPS score, (The number 2 in our example), represents the grouping step and comes from the number of visits expected. In this case, the 2 stands for early episodes, 14-19 visits.
Position #2 of the HIPPS score, (The letter C in our example), represents the Clinical Domain and translates from the HHRG score of C3.
Position #3 of the HIPPS score, (The letter G in our example), represents the Functional Domain and translates from the HHRG score of F2.
Position #4 of the HIPPS score (The letter K in our example), represents the Service Domain and translates from the HHRG score of S1.
As stated in my previous blog article from January 28, 2013, Providers who receive an Additional Documentation Request (ADR) must submit the requested medical record information within 30 days to:
Palmetto GBA
J11 Part A Medical Review
Mail Code: AG-230
P.O. Box 100238
Columbia, SC 29202-3238
Or fax to (803) 699-2436.
Agencies may check DDE for pending ADRs as well. To do so, log into your DDE account, then go to the inquiry screen (01), then (12) for claims summary, then put in claim location SB6000 to review claims awaiting the creation of an ADR. Claims with status SB6001 are those claims which have been selected and awaiting a provider response to an ADR letter. By checking DDE, you may have additional days to collect, copy, review and ready your claim for submittal because you can see ADR status in DDE before you receive the actual mailed ADR letter from Palmetto.
