Page 15 - Rehab 2020

MEDICARE REIMBURSEMENT

Medicare has covered home care services since 1963.

OASIS – Outcome Assessment Information Set
1. A standardized set of questions which all certified home care agencies must use
2. It is a tool to measure outcomes and determines payment of home care services (PPS)

PPS – Prospective Payment System
1. This system is a fixed sum payment.
2. Home care services is based on a 60-day episode of care. Re-certification constitutes a new
episode of care.
3. The payment for all home care services is based on a fixed rate per 30-day payment period.
There can be up to two payment periods within a 60-day episode of care.
4. The OASIS assessment provides a HIPPS score, which determines the amount of payment
for the episode of care.
a. Individual characteristics are divided into clinically meaningful domains.

HIPPS Code –
1. Responses to specific OASIS questions are organized into 5 domains which produce the
HIPPS code:
1. Admission Source: Institutional vs. Community
2. Timing: Early vs Late
3. Clinical Grouping: Based on the primary reason for Home Health services
4. Functional Impairment Status: Low vs. Medium vs. High
Affected by patient’s level of assist for:
• Grooming
• Upper Body Dressing
• Lower Body Dressing
• Bathing
• Toilet Transferring
• Transferring
• Ambulation/ Locomotion
• Risk for Hospitalization
5. Comorbidity Adjustment; None vs. Low vs. High
2. Each domain has an impact on reimbursement and should be considered during utilization
3. There are 432 case-mix weights/codes.

PPS has payment variations
1. LUPA: Low Utilization Payment Adjustment- 30-day periods with a low number of visits are
not case-mix adjusted (paid for the entire 30-day period), but instead paid on a per-visit
basis.
a. LUPA thresholds are variable dependent upon HIPPS code and currently ranges
between 1-5 visits per 30-day period.

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