(Medicare Claims Processing Manual)

3.3. Subtract the outlier threshold from the imputed cost.  3.4. If the result determined in step 3.3 is greater than $0.00, calculate .80 times the result.  This is the outlier payment amount.   3.5. Determine whether the outlier payment is subject to the 10% annual limitation on outliers as follows:    Multiply the amount in the PROV -PAYMENT -TOTAL field by 10 percent to determine the HHAs outlier limitation amount.    Deduct the amount in the PROV -OUTLIER -PAY -TOTAL from the outlier limitation amount.   This result is the available outlier pool for the HHA.    If the available outlier pool is greater than or equal to the outlier payment amount calculated in step 3.4, return the outlier payment amount in the OUTLIER -PAYMENT field.  Add this amount to the total dollar amount resulting from HRG payment calculatio n.  Return the sum in the TOTAL -PAYMENT field, with return code 01.    If the available outlier pool is less than the outlier payment amount calculated in step 3.4, return no payment amount in the OUTLIER -PAYMENT field.  Assign return code 02 to this record.   a. If the result determined in step 3.3 is less than or equal to $0.00, the total dollar amount resulting from all HRG payment calculations is the total payment.  Return zeroes in the OUTLIER -PAYMENT field.  Return the HRG payment amount in the TOTAL -PAYMENT field, with return code 00.   4. Late- filed NOA payment penalty:   4.1  If the value in OVERRIDE -IND is equal to Y, continue to step 5.   4.2  If the span of days between the FROM -DATE and RECEIPT -DATE is greater than five and the value inOVERRIDE -IND is equal to N, reduce the HRG -PAY and OUTLIER -PAYMENT amounts by the span of days/30.    4.3  Subtract the sum of theHRG -PAY and OUTLIER -PAYMENT amounts reduced by the late -filed NOA penalty from step 4.2 from the sum of the HRG -PAY and OUTLIER -PAYMENT amounts before the penalty.  Return the result in LATE -SUB -PENALTY -AMT. Continue t o step 5.  5.  Value -Based Purchasing Adjustment:   Multiply all payment amounts by adjustment factor in PROV -VBP -ADJ-FAC.  Return the results as the final Medicare payment amounts in all appropriate output fields.   Subtract the total payments calculated in steps 2 through 4 from the total VBP -adjusted payments calculated in step 5.   Return the difference in the VBP -ADJ-AMT field.    70.5 - Annual Updates to the HH Pricer  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  Rate and weight information used by the HH Pricer is updated periodically, usually annually.  Updates occur each January, to reflect the fact that HH PPS rates are effective for a calendar year.  Updates may also occur at other points in the year when required by legislation.  The following update items, when changed, are published in the Federal Register :   The Federal standard period of care amount;    The fixed loss amount to be used for outlier calculations;    A table of case- mix weights and LUPA thresholds to be used for each HHRG;    A table of national standardized per visit rates and per unit rates;    The pre -floor, pre -reclassified hospital wage index; and    Changes, if any, to the outlier loss -sharing percentage and the labor and nonlabor percentages.   Whenever these update items change, Medicare also publishes a Recurring Update Notification to inform providers and A/B MACs (HHH) about the changes.  These Recurring Update Notifications also describe how the changes will be implemented through the HH Pri cer.  80  HH Grouper Program  (Rev. 11644, Issued: 10- 13-22, Effective: 04 -01-23, Implementation: 04- 03-23)  The Home Health Resource Group (HHRG) used to pay home health services billed on TOB 032x are determined by the HH Grouper program.  HHRGs are represented on claims in the form of HIPPS codes.  Like the HH Pricer, the HH Grouper is a module within Medicare  claims processing systems.  The HHA sends a HIPPS code on the claim, using revenue code 0023.  Medicare systems combine claim data and OASIS data and send the data to the HH Grouper to determine the HIPPS code used for payment.  The HIPPS code from the Gr ouper replaces the provider -submitted HIPPS code on the claim and is then sent to the HH Pricer for payment calculations.   Medicare claims processing systems send an input record to Grouper for all claims and most adjustments.  Medical review or other program integrity contractor adjustments are not sent to the Grouper.  The Grouper returns an output record to the shared syste ms whenever an input record is sent.    No part of the Grouper logic is required to be incorporated into an HHAs billing system in order to bill Medicare, unless the HHA chooses to do so to assist their accounts receivable functions.  The following is presented for A/B MACs (HHH) and as information for the HHAs, in order to help HHAs understand how their HH claims are processed.   80.1  HH Grouper Input/Output Record Layout  (Rev. 11644, Issued: 10- 13-22, Effective: 04 -01-23, Implementation: 04- 03-23)  The required data and format for the HH Grouper input/output record for periods of care beginning on or after January 1, 2020 are shown below:    File Position  Format  Title  Description  1 - 24 X(24)  Claim ID  Input item: Document control number of the claim record.  25-32 X(8)  From Date  Input item: The Statement Covers From date from the claim, in format CCYYMMDD  33 9 Period Timing  Input item: Set to 1 when claim From  date matches Admission date or when a CWF sequence edit is received.  Otherwise, set to 2.  34 - 35 9(2) Referral Source  Input item: If occurrence code 61 or 62 are present on the claim, the code value is moved to this field.  The occurrence date is not moved.  36 - 42 X(8)  Principal Diagnosis  Input item:  The principal diagnosis code from the claim.  43 - 50 X(8)  Secondary Diagnosis  Input item:  The first secondary diagnosis code from the claim.  51 - 235 Defined above  Additional Secondary Diagnosis data  Input items: 23 additional occurrences of secondary diagnoses from the claim.  236-275 X(40)  Filler  For future use.  276 9 M1033 -HOSP -RISK -HSTRY-FALLS  Input item: Moved from the M1033 -HSTRY -FALL field on the QIES/OASIS screen in FISS.   Valid values: 0,1 277 9 M1033 -HOSP -RISK -WEIGHT -LOSS  Input item: Moved from the M1033 -WEIGHT -LOSS field on the QIES/OASIS screen in FISS.  Valid values: 0,1 278 9 M1033 -HOSP -RISK -MLTPL-HOSPZTN Input item: Moved from the M1033 -MLTPL -HOSPZTN field on the QIES/OASIS screen in FISS.  Valid values: 0,1  File Position  Format  Title  Description  279 9 M1033 -HOSP -RISK -MLTPL-ED-VISIT  Input item: Moved from the M1033 -MLTPL -ED-VISIT field on the QIES/OASIS screen in FISS.  Valid values: 0,1 280 9 M1033 -HOSP -RISK -MNTL -BHV- DCLN  Input item: Moved from the M1033 -MNTL -BHV -DCLN on the QIES/OASIS screen in FISS. Valid values: 0,1 281 9 M1033 -HOSP -RISK -COMPLIANCE Input item: Moved from the M1033 -COMPLIANCE on the QIES/OASIS screen in FISS.  Valid values: 0,1  282 9 M1033 -HOSP -RISK -5PLUS -MDCTN Input item: Moved from the M1033 -5PLUS -MDCTN on the QIES/OASIS screen in FISS.  Valid values: 0,1 283 9 M1033 -HOSP -RISK -CRNT -EXHSTN Input item: Moved from the M1033 -CRNT -EXHSTN on the QIES/OASIS screen in FISS.  Valid values: 0,1 284 9 M1033 -HOSP -RISK -OTHR -RISK  Input item: Moved from the M1033 -OTHER -RISK on the QIES/OASIS screen in FISS.  Valid values: 0,1 285 9 M1033 -HOSP -RISK -NONE -ABOVE  Input item: Moved from the M1033 -NONE -ABOVE on the QIES/OASIS screen in FISS.  Valid values: 0,1 286-287 9(2) M1800 -CRNT -GROOMING  Input item: Moved from the M1800 -CRNT -GROOMING on the QIES/OASIS screen in FISS.  Valid values: 00,01, 02, 03 288-289 9(2) M1810 -CRNT -DRESS -UPPER  Input item: Moved from the M1810 -DRESS -UPPER on the QIES/OASIS screen in FISS.  Valid values: 00,01, 02, 03 290-291 9(2) M1820 -CRNT -DRESS -LOWER  Input item: Moved from the M1820 -DRESS -LOWER on the QIES/OASIS screen in FISS.  Valid values: 00,01, 02, 03 292-293 9(2) M1830 -CRNT -BATHG Input item: Moved from the M1830 -CRNT -BATHG on the QIES/OASIS screen in FISS.  Valid values: 00,01, 02, 03, 04, 05, 06 File Position  Format  Title  Description  294-295 9(2) M1840 -CRNT -TOILTG  Input item: Moved from the M1840 -CRNT -TOILTG on the QIES/OASIS screen in FISS.  Valid values: 00,01, 02, 03, 04 296-297 9(2) M1850 -CRNT -TRNSFRNG Input item: Moved from the M1850 -CRNT -TRNSFRNG on the QIES/OASIS screen in FISS.  Valid values: 00,01, 02, 03, 04, 05 298-299 9(2) M1860 -CRNT -AMBLTN  Input item: Moved from the M1860 -CRNT -AMBLTN on the QIES/OASIS screen in FISS.  Valid values: 00,01, 02, 03, 04, 05, 06 300-599 X(301)  Filler  For future use.  601-607 X(7)  Version Used  Output item:  The version of the HH Grouper which grouped the current claim.  Informational only.  608-612 X(5)  HIPPS Code  Output item:  The HIPPS code determined by grouping the input items above.  Moved to the HCPCS code field of revenue code 0023 line of the claim.  613-614 9(2) Validity Flag  Output item: Beginning April 1, 2023, the specific diagnosis coding issue that requires a claim to be returned to the provider.  615-616 9(2) Grouper Return Code  Output item: Identified technical issues that may cause no HIPPS code to be assigned.  617-700 X(84)  Filler  For future use.