Ga. Medicaid Part II Policies & Procedures for Hospice Services § 1006

Payments to a hospice for inpatient care must be limited according to the number of days or inpatient

care furnished to Medicaid patients. During the 12-month period-beginning November 1 of each year

and ending October 31, the aggregate number of inpatient days (both for general inpatient care and

inpatient respite care) may not exceed 20 percent of the aggregate total number of days of hospice

care provided to all Medicaid members during that same period. Effective with services on and after

July 1, 1988, this calculation will exclude days for AIDS patients. This limitation is applied once

each year, at the end of the hospice’s “cap period” (11/1-10/31). For purposes of this computation, if

it is determined that the inpatient rate should not be paid, any days for which the hospice receives

payment at a home care rate will not be counted as inpatient days. Calculate the limitation as

follows:

1006.1. The maximum allowable number of inpatient days will be calculated by multiplying the

total number of days of Medicaid hospice care by 0.20.

1006.2. If the total number of days of inpatient care furnished to Medicaid hospice patients is

less than or equal to the maximum, no adjustment will be necessary.

1006.3. If the total number of days of inpatient care exceeded the maximum allowable number,

the limitation will be determined by:

1006.3.1. calculating a ratio of the maximum allowable inpatient care days to total

number of actual days of inpatient care and multiplying this ratio by the

total reimbursement for inpatient care (general inpatient and inpatient

respite reimbursement) paid to the provider.

1006.3.2. multiplying excess inpatient care days by the routine home care rate.

1006.3.3. adding together the amounts calculated in 1. and 2. above.

1006.3.4. comparing the amount in 3. above with interim payments made to the

hospice for inpatient care during the “cap period”.

1006.3.5. Any excess reimbursement must be refunded by the hospice to the

Division.

1006.4. National Correct Coding Initiative and Medically Unlikely Edits

On October 1, 2010, the Centers for Medicare and Medicaid services (CMS) directed

all state Medicaid agencies to implement the National Correct Coding Initiative (NCCI)

as policy in support of Section 6507 of the Affordable Care Act of March 23, 2010.

NCCI was implemented to promote correct coding methodologies and to control

improper coding leading to inappropriate payment.

A part of the NCCI regulations required State Medicaid Agencies to implement

Medically Unlikely Edits (MUEs) and units-of-service (UOS) edits. The NCCI /MUEs

limit the frequency (number of units) billed for individual procedure codes. Procedure

codes submitted with frequencies greater than their MUE or UOS will be mass adjusted,

but not paid.

Likewise, claims also may not pay for specific services. DCH is willing and has at

times requested deactivation of edits to allow claims to adjudicate. However, the

permission to deactivate certain edits must come from CMS. Information on new

requirements from CMS will be posted on their website.

For additional information on NCCI edits and review sample procedure to procedure

(PTP) ode sets, refer to the following CMS website:

http://www.cms.gov/MedicaidNCCICoding/.