Home Health Agency Prospective Payment System (PPS) Claims Calculator

Published 02/11/2021

The Balanced Budget Refinement Act of 1999 required each Medicare home health agency (HHA) to be paid on the basis of a prospective payment amount through the Home Health Prospective Payment System (HH PPS) for episodes starting on or after October 1, 2000, through December 31, 2019. Effective for periods of care beginning on and after January 1, 2020, the original HHA PPS system is replaced with the Patient-Driven Grouping Model (PDGM). PDGM changes the episode period from 60-days under HHA PPS to 30-days, and the number case mix groups (HIPPS codes) to 432. In addition, each case mix group has a LUPA threshold. If the number of visits on the claim are under this LUPA threshold the claim will be reimburse as a Low Utilization Payment Adjustment (LUPA).

To assist home health providers in determining reimbursement for Medicare home health PPS/PDGM claims, Palmetto GBA offers providers the ability to estimate their claims payment amount online. The online calculator is designed to estimate the amount of reimbursement for all types of Medicare HHA claims with service episodes/periods beginning on or after October 1, 2000.

Effective 2007, the Deficit Reduction Act (DRA) requires home health providers to submit Required Quality Data in order to receive full reimbursement for episode/period payments in the current year and thereafter. For those providers who have not submitted the required data, episode payments will be reduced two percent (2%).

In order to estimate the claims reimbursement, you will need to know the following:

Core Based Statistical Area (CBSA) code for the county in which the services are provided (MSA codes for services prior to 2007)

Home Health Resource Group (HHRG)/Health Insurance Prospective Payment System (HIPPS)/PDGM weights

Required Quality Data has been reported (Y/N)

NRS Severity Level (1–6)

Initial or only LUPA episode (Y/N)

Number of days of care by initial HHA (PEPs only)

View the Claims Calculator

*If you do not know the MSA code or CBSA code that represents the location from which the services were rendered, you can find it while in the calculator by entering the state and selecting the county. If the county from which the services were rendered is not listed you should select Non-MSA or All Other Counties.

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