Edit PPS Episodes Screen


Below is an explanation on some of the fields in the Billing > PPS Billing > Edit PPS Episodes screen.

Top, center, two sets of dates: Admit date and Discharge date from the referral.  Below that is the From and Thru dates of the End of Episode claim. 

Select Different OASIS: When the RAP> update runs, the default option is exported OASIS. If an OASIS is locked but not exported, the episode & the OASIS disconnect. Use this button to reconnect them.

HIPPS: HIPPS code and amount from the time of RAP

RAP Date: Date RAP created

RAP Serial #: The serial number that was used to create the RAP claim

RAP Date Paid: Most recent date the RAP was paid

RAP $Paid:  The amount of RAP paid (this will be a zero when the RAP payment is reversed, from the RAP being cancelled or the EOE being paid)

EOE Date: Date EOE created

EOE Serial #: The serial number that was used to create the EOE claim

EOE Date Paid: Date the EOE was paid

EOE $Paid:  The total amount paid for the episode.  When this does not match the $ Expected, then one of the Reason(s) for not receiving full payment should be checked.

Calculated HIPPS: The calculated HIPPS code at the end of the episode (after factoring in the actual number of therapy visits, and whether there were any supply charges)

$ Expected:  The amount from the calculated HIPPS code at the end of the episode

LUPA $ Total:  The number of discipline visit times the LUPA amount.  Example, a LUPA SN visit for a selected county is $100 per visit, LUPA PT visit for a selected county is $105.  A patient had 2 SN visits and 1 PT visit in one episode.  The total amount that would show is $305.

Fixed $ Loss:  Each year, CMS publishes guidelines for calculating the outlier payment, for episodes with a large number of visits.  The “fixed dollar loss” is part of that calculation.

$Outlier: This is the additional amount to be added to the HIPPS code payment due to a large number of visits.

Supplies Used $:  The amount of supplies used during that episode

Status: 1 = 485 created but no OASIS; 2 = 485 and OASIS created but no chargeable visit;  3 = 485, OASIS, chargeable visit entered but no RAP created;  4 = RAP Sent but not paid OR RAP sent and paid but EOE not sent yet ; 5 = EOE sent but not paid  ;  6 = Episode is Paid ; 8 = Episode On Hold.

PT, OT, ST, SN, MS, HCA:  The number of chargeable visits made during that episode.

Reason(s) for not receiving full payment:  Some of these are under your control, and some are decided by PGBA during processing.  If an episode is ultimately denied, or due to other circumstances ends up not being paid, then you can check that box to tell the software to drop this episode off the list.  LUPA is automatically checked when the EOE is created if there are less than 5 total visits.  Outlier is checked if the Outlier$ is not $0.  PEP, MSP and Medical Review Downcode can be checked by the agency.  PEP will be used on the 15.16 PPS Cost Reports.

OASIS #1, #2 and #3 Were used prior to 2008, when the billing rules allowed more than one OASIS HIPPS code to be sent with the EOE claim.  Since then the OASIS #1 line will show the details from the OASIS used to bill the episode.