Ga. Medicaid Part II Policies & Procedures for Hospice Services § 1002

The following provides instruction on how to bill the Hospice Routine Home Care (RHC) and the

Service Intensity Add-on (SIA) claims for members who have elected and receive Hospice care as of

January 1, 2016. Effective for claims with a Date of Service (DOS) on or after 09/1/2016, providers

should bill as indicated for the hospice pricing periods:

1002.1. The RHC (Revenue Code 651) ‘higher’ rate, billed for days 1 through 60 for members

who have elected Hospice.

1002.2. The second RHC (also Revenue code 651) ‘lower’ rate, billed from day 61 until the

date of death.

1002.3. The last rate is the SIA rate, which is the add-on rate, is billed during the last seven

days of life. The SIA is billed on a separate claim. Successful adjudication of the SIA

claim is dependent on the related paid RHC claim in GAMMIS history. The SIA Claim

may cover up to the last seven days of life and include the Date of Death (DOD). The

Hospice SIA claim’s Header through Date of Service (TDOS) must equal the patient’s

date of death. The SIA payment will be equal to the Continuous Home Care (CHC)

hourly payment rate. Billing is to be for a minimum of 15 minutes and maximum of 4

hours in each day per the RHC day. An SIA claim will deny if a claim for CHC for the

same member/same day was paid, and vice versa.

1002.3.1. The SIA service must be billed on a separate claim, and not with any

other Hospice Service billed.

1002.3.2. Only one SIA claim is allowed per member for all end-of-life SIAs

during the last 7 days of life. Multiple SIA claims are not allowed for the

same member.

1002.3.3. The SIA must have a distinct DOS, i.e., providers cannot bill multiple

days on a single detail line. Multiple detail lines may be billed on a

single claim.

1002.3.4. Only the Patient Discharge Status (PDS) 40, 41, or 42 may be used for

SIA claims. PDS 20 will not be accepted for Hospice SIA claims with

DOS on or after 9/1/2016.

1002.3.5. The Through Date of Services (TDOS) on an SIA claim must equal the

member’s DOD.

1002.3.6. The SIA Service is limited to 16 units (4 hours) per day.

1002.4. If the TDOS does not match the DOD on the member’s file, the claim will deny.

1002.5. If there is no DOD on the member’s file, the claim will suspend.

1002.6. The suspended claim will recycle in GAMMIS for 60 days for the Member file to

update with the DOD.

1002.7. If the DOD is not loaded on the Member file within the 60 days, the SIA claim will

deny.

1002.8. If the DOD is loaded on the Member file within the 60 days, the SIA claim will be

released from suspending and continue processing for applicable editing or payment.

1002.9. Effective for claims with a Date of Service (DOS) on or after 9/1/2016, when billing the

following Hospice Revenue Codes, providers must select the most appropriate CPT

code, and a valid CPT code must be present for the claim to adjudicate successfully.

The new hospice pricing periods are as described, below, and billed as indicated in the

following Hospice Revenue Code Chart. 1) When billing for the Registered Nurse

Service, the claim must be billed with Revenue Code 551, and Procedure

Code/Modifier Combination G0299 RN, and Patient Status 40, 41, or 42.

1002.9.1. When billing for the Social Worker Service, the claim must be billed

with Revenue Code 561, and Procedure Code/Modifier Combination

G0155 SW, and Patient Status 40, 41, or 42.

1002.9.2. For Patient Discharge Status -- Do Not Use Status Code 20 for Hospice

SIA claims.

1002.9.3. No other procedure codes should be included on a SIA claim.

Pricing Period Rev Code Modifier Days Rate

Routine Home

Care

651

with Procedure

Code described

below

N/A 1-60 Higher

Routine Home

Care

651

with Procedure

Code described

below

N/A 61-up Lower

Service Intensity

Add-On

551

with Procedure

Code G0299

RN Last 7 days of life

(billed in 15-minute

increments)

Add-on (if

applicable)

Service Intensity

Add-On

561

with Procedure

Code G0155

SW Last 7 days of life

(billed in 15-minute

increments)

Add-on (if

applicable)

1002.9.4. When billing for revenue code 651, procedure codes (Q5001-Q5010)

must be present.

1002.9.5. When billing for revenue code 652, procedure codes (Q5001-Q5003,

Q5009Q5010) must be present.

1002.9.6. When billing for revenue code 655, procedure codes (Q5003-Q5009)

must be present.

1002.9.7. When billing for revenue code 656, procedure codes (Q5004-Q5009)

must be present.