CMS Pub. 100-04, ch. 10, § 70

Home health services billed on TOB 032x are reimbursed based on calculations made by

the HH Pricer. The HH Pricer is a module within Medicare claims processing systems.

The HH Pricer makes all payment calculations applicable under HH PPS, including

claim payments for full periods of care, and all payment adjustments.

Medicare claims processing systems maintain a client that communicates with the HH

Pricer application programming interface (API). The Pricer is made available

electronically to the shared systems and is updated at least annually.

The API describing the elements of HH PPS claims that are used and the source code

that calculates payments in the HH Pricer are available to HHAs and their software

vendors at: https://www.cms.gov/pricersourcecodesoftware. This is code is shared

informationally. No part of the HH Pricer logic is required to be incorporated into an

HHA’s billing system in order to bill Medicare.

A web-based version of the HH Pricer Program that may be used to estimate HH PPS

payments can be found at: https://webpricer.cms.gov/ .

Annual Updates to the HH Pricer

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 Pricer.