ModifiedMedicaPolicy N/A

HIPPS codes (Health Insurance Prospective Payment System rate codes)

Defines HIPPS codes, their structure, uses across Medicare prospective payment systems (SNF, HH, IRF), effective dates, and how they are reported on institutional claims; affects institutional providers submitting HIPPS-coded claims.

Policy Summary

PayerMedica

PolicyHIPPS codes (Health Insurance Prospective Payment System rate codes)

Policy CodePolicy N/A

Change TypeMaterial: PDGM adoption for Home Health (effective Jan 1, 2020)

Effective DateOct 1, 2019

Next Review Date

Key ActionReport HIPPS codes on institutional claims in data element SV202 (electronic 837 institutional) or Form Locator 44, with the associated revenue code in SV201 or FL 42.

SourceLink

POLICY UPDATE CHANGES

Beginning January 1, 2020, the HH PPS case-mix system is replaced with the Patient-Driven Groupings Model (PDGM) using 30-day periods and 432 HHRG/HIPPS codes.

432valid Home Health HIPPS/HHRG codes under PDGM

28800theoretical PDPM combinations

14275PDPM first-four combos

447valid IRF HIPPS codes (post-2019)

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legacy HH HIPPS (2007 structure)

5characters per HIPPS code

HIPPS Coding Structures and PPS Rules

inv-01: Coding structures and system-specific rules

Structure and usage rules for HIPPS codes by payment system (SNF PDPM, SNF RUG‑IV, Home Health HH PPS):

ALL of the following

PDPM replaced RUG‑IV beginning October 1, 2019; PDPM HIPPS use five positions to represent multiple case‑mix components and an assessment indicator (AI). The first position represents combined Physical and Occupational case‑mix groups; the second represents Speech‑Language Pathology; the third represents Non‑Therapy Ancillary; the fifth represents the AI code.
ALL of the following
- PDPM includes 16 PTIOT groups, 12 SLP groups, 25 Nursing groups and 6 NTA groups resulting in 28,800 theoretical combinations; exclusions for clinical-category conflicts and function‑score rules reduce valid first‑four‑character combinations to 14,274, plus a default ZZZZZ, yielding 14,275 possible first‑four character combinations under SNF PDPM.
- SNF HIPPS codes (PDPM or RUG structures) are only valid on claim lines reporting revenue code 0022.

ALL of the following

Under legacy HH PPS (pre‑2008 and 2008 refinements) the HIPPS code positions mapped to case‑mix groups and NRS severity levels; the second through fourth positions accepted only alphabetical characters for certain legacy structures.
Beginning January 1, 2020, HH PPS case‑mix was replaced by PDGM: payment periods are 30 days and PDGM uses 432 HHRG/HIPPS codes. PDGM HIPPS positions map as: position 1 = Source & Timing; position 2 = Clinical Group; position 3 = Functional Level; position 4 = Co‑Morbidity; position 5 = Placeholder.
HIPPS codes generated using any Home Health coding structure are only valid on claim lines reporting revenue code 0023.

ALL of the following

IRF HIPPS codes are produced by the IRF‑PAI Grouper using IRF‑PAI assessment data. The first position is an alphabetic comorbidity tier (A, B, C, D). Positions two through five represent the CMG/RIC and functional motor/cognitive measures; the fifth position permits numeric values in a specified range and includes a default (e.g., 9999).
IRF HIPPS code set changed over time with additions/deletions (most recently through October 1, 2019), resulting in 447 valid IRF HIPPS codes.
HIPPS codes created using the IRF structure are only valid on claim lines reporting revenue code 0024.

inv-02: PPS HIPPS coding and claim-reporting rules

Stance on coding and claim reporting for PPS‑based services:

ALL of the following

Report HIPPS codes on institutional claims in the appropriate HIPAA data element (SV202 on electronic 837 institutional) or Form Locator 44; associated revenue code must be reported in SV201 or Form Locator 42. Multiple HIPPS codes may appear on separate lines of a single claim when appropriate.

Home Health (PDGM) claims

Effective January 1, 2020, Home Health claims must use PDGM HHRG HIPPS codes representing 30‑day PDGM periods; HHRG components map to HIPPS positions (Source & Timing, Clinical Group, Functional Level, Co‑Morbidity, Placeholder).effective Jan 1, 2020
Home Health HIPPS codes (PDGM or legacy structures) are valid only on claim lines reporting revenue code 0023.

Legacy Home Health HIPPS acceptance

Code Examples, PDGM and Legacy HIPPS Lists

Examples and defaultsmixed

ZZZZZ	Default code for SNF PDPM when applicable (explicit default present in combinations)
Hxxxx	Home Health HIPPS codes historically began with fixed 'H' (pre-2008 structure)

Home Health PDGM codes (sample)mixedCovered

PDGM HHRG/HIPPS set

432 unique HIPPS codes representing HHRGs for 30-day PDGM periods (positions: Source & Timing, Clinical Group, Functional Level, Co-Morbidity, Placeholder).

Legacy HH HIPPS (example)mixed

2008/2007 HH HIPPS set

Earlier HH HIPPS code set: 153 case-mix groups × 6 NRS levels = 918 HIPPS codes (accepted on claims with 'From' dates on or before 12/31/2019).

IRF HIPPS (example)mixed

IRF HIPPS set

Alphanumeric IRF HIPPS: position 1 = comorbidity tier (A-D), positions 2-5 = CMG/RIC and functional motor/cognitive measures; 447 valid codes after 2019 updates (default and atypical codes noted).

PDGM HHRG/HIPPS codesmixedCovered

PDGM HHRG/HIPPS set

432 valid HIPPS codes representing Home Health Resource Groups for 30-day PDGM payment periods (positions: 1=Source & Timing, 2=Clinical Group, 3=Functional Level, 4=Co-Morbidity, 5=Placeholder).

Legacy Home Health HIPPS (2000–2019)mixed

2008/2007 HH HIPPS set

Home health HIPPS where position 1='H' and positions 2-4 map to HHRG domains (153 case-mix groups) with position 5 as NRS/default indicator; 153 × 6 = 918 codes. Medicare accepts the October 2008 HH HIPPS code set only on claims with 'From' dates on or before 12/31/2019.

IRF HIPPS codesmixed

IRF HIPPS set

IRF HIPPS: 5-character alphanumeric codes with position 1 = comorbidity tier (A=none, B=high, C=medium, D=low), positions 2–5 = CMG (RIC and functional motor/cognitive measures; valid values include ranges 0101–5104 and default 9999); 447 valid codes after updates. IRF HIPPS are valid only on claim lines reporting revenue code 0024.

inv-07: HIPPS code effective rules — Effective From/Through and transaction-date rules under HIPAA.

HIPAA transaction-date ruleHIPPS codes are defined as a non‑medical code set and are effective by transaction date (valid on transactions on or after the 'Effective From' date)

Effective From dateHIPPS Code Master List shows each code's 'Effective From' date; codes are valid on transactions dated on or after this date

Effective Through handlingCodes may include 'Effective Through' limits on the master list; validity on transactions is determined by transaction (not solely service) date per HIPAA rules

Claims for earlier service datesA claim for dates of service before a code's 'Effective From' date could be submitted on a later transaction, but HIPAA defines effectiveness by the transaction date

Claim Reporting and Billing Requirements

Billing Rule

Claim reporting requirements

Institutional providers must report HIPPS codes on claims using the revenue-code-specific requirements for each prospective payment system. Enter HIPPS codes in data element SV202 (electronic 837 institutional) or Form Locator (FL) 44 on paper claims, and report the associated revenue code in SV201 / FL 42. Multiple HIPPS codes may appear on separate claim lines when applicable; each HIPPS must be paired with the correct revenue code on its line.

HIPPS codes go in SV202 / FL 44 on institutional claims.
Associated revenue code goes in SV201 / FL 42 on institutional claims.
Multiple HIPPS codes must be reported on separate claim lines, each with its revenue code.

Billing Rule

HH PDGM HIPPS reporting

Report 30‑day Home Health (HH) PDGM HIPPS codes on claim lines that use revenue code 0023 only. The HIPPS value must come from the HH Grouper output for the appropriate 30‑day period. Ensure Source & Timing and period mapping are correct so the HIPPS reflects the assessment period that covers the billed 30‑day episode. There is a 1:1 relationship between HHRGs and HH HIPPS codes; only codes generated from the HH coding structure are valid on lines with revenue code 0023.

Key Terms

inv-11: HIPPS code — 5-character alpha-numeric code representing a case-mix group and assessment indicators used in prospective payment systems.

DefinitionA 5‑character alphanumeric code representing a case‑mix group and assessment indicators used by prospective payment systems

Use on claimsHIPPS codes are reported in data element SV202 on the electronic 837 institutional transaction or in Form Locator 44, paired with the associated revenue code in SV201 or FL 42

Association with revenue codesEach prospective payment system that requires HIPPS codes has a defined revenue code; HIPPS appear on claim lines in association with that revenue code

inv-12: Assessment instrument — clinical standardized assessments (MDS, OASIS) that feed grouper software.

DefinitionClinical standardized assessment instrument (e.g., MDS, OASIS) that provides the clinical input data used by grouper software to assign case‑mix groups

Policy Summary

PayerMedica

PolicyHIPPS codes (Health Insurance Prospective Payment System rate codes)

Policy CodePolicy N/A

Change TypeMaterial: PDGM adoption for Home Health (effective Jan 1, 2020)

Effective DateOct 1, 2019

Next Review Date

Key ActionReport HIPPS codes on institutional claims in data element SV202 (electronic 837 institutional) or Form Locator 44, with the associated revenue code in SV201 or FL 42.

SourceLink

On This Page

Medicare accepts the October 2008 HH HIPPS code set only for claims with 'From' dates on or before 12/31/2019; legacy HH HIPPS (2007/2008 structures) are not accepted for later claim periods.

IRF HIPPS reporting

IRF providers must run the IRF‑PAI Grouper to assign IRF HIPPS codes derived from IRF‑PAI assessment data; the Grouper outputs the HIPPS code that must be entered on the claim.
IRF HIPPS are valid only on claim lines reporting revenue code 0024.

Operational note: Ensure HIPPS code effective dates align with the claim 'From'/'Through'/transaction dates; HIPPS code reporting and revenue code pairing must follow the system‑specific revenue code rules (SNF=0022, HH=0023, IRF=0024).

Enter HH PDGM HIPPS on claim lines with revenue code 0023 only.
Use the HH Grouper output for the specific 30‑day period to determine the HIPPS code.
Map assessment Source & Timing correctly so the HIPPS matches the billed period.

Billing Rule

IRF HIPPS reporting

Enter IRF HIPPS exactly as produced by the IRF‑PAI Grouper output on the claim. IRF HIPPS codes are valid only on claim lines reporting revenue code 0024. The IRF HIPPS is a five‑position alphanumeric code: position 1 = comorbidity tier (A–D); positions 2–3 = Rehabilitation Impairment Category (RIC); positions 4–5 = CMG functional values (numeric). Do not submit atypical IRF CMG codes that CMS designates as provider‑non‑submit (e.g., A5001, A5101, A5102, A5103, A5104) — those are assigned by Medicare systems. The IRF default code (9999) is combined only with comorbidity A and is used for informational-only managed care claims.

Enter IRF HIPPS on claim lines with revenue code 0024 only.
Use the IRF‑PAI Grouper output to determine the HIPPS code.
IRF HIPPS format: 1st position = comorbidity tier (A–D); positions 2–5 = CMG and functional values (e.g., 0101–5104 or 9999).
Do not submit CMS-designated atypical CMG HIPPS codes from the provider (A5001, A5101, A5102, A5103, A5104).

Role in HIPPS assignment

Assessment instrument outputs are interpreted by case‑mix grouping algorithms to produce the HIPPS code representing the case‑mix group

Source examplesMDS for SNF and OASIS for Home Health are cited as standard instruments feeding grouper software

inv-13: HHRG (PDGM/PDPM) — Home Health Resource Group definition and PDGM components (Source & Timing, Clinical Group, Functional Level, Co-morbidity, placeholder).

DefinitionHome Health Resource Group (HHRG) — grouping used under PDGM combining Source & Timing, Clinical Group, Functional Level, Co‑morbidity, and a placeholder to produce a single HIPPS code for a 30‑day period

PDGM period lengthPDGM replaces 60‑day episodes with up to 30‑day payment periods; HHRGs map to 30‑day HIPPS codes

Code positionsHIPPS/HHRG positions: Position 1 = Source & Timing; Position 2 = Clinical Group; Position 3 = Functional Level; Position 4 = Co‑Morbidity; Position 5 = Placeholder

Number of valid codesUnder PDGM there is a 1:1 relationship between HHRGs and HIPPS codes, resulting in 432 valid Home Health HIPPS/HHRG codes

inv-14: CMG — Case Mix Group for IRF derived from IRF-PAI assessments, with comorbidity tier and functional measures.

DefinitionCase Mix Group (CMG) — IRF case‑mix grouping derived from IRF‑PAI assessment data and represented in IRF HIPPS codes

IRF HIPPS structureFirst position = alphabetic comorbidity tier (blank/ A/B/C/D per tier definitions); positions 2–5 represent CMG/RIC and functional motor/cognitive measures

Valid values and defaultsFifth position allows numeric values in ranges (0101–5104) and 9999 as a default; not all numeric values in the range are used

Grouper requirementIRF providers must run the IRF‑PAI Grouper to assign HIPPS codes; Grouper outputs must be entered on the claim