Ga. Medicaid Part II Policies & Procedures for Hospice Services § 903

All services must be performed by appropriately qualified personnel, but it is the nature of the

service, rather than the qualification of the person who provides it, that determines the coverage

category of the service. The services below are covered hospice services:

903.1. Nursing Care provided by or under the supervision of a registered nurse. (This includes

care provided by an advanced nurse practitioner and LPN or Home Health Aide

supervised by a RN).

903.1.1. Advance Nurse Practitioners may enroll and provide hospice care in four

categories of service: pediatric, family, adult and gerontological,

OBGYN and certified registered nurse anesthetist (CRNA).

903.2. Medical Social Services provided by a social worker who has at least a bachelor’s

degree from a school accredited or approved by the Council on Social Work Education,

and who is working under the direction of a physician.

903.3. Physicians’ Services provided by the hospice medical director or physician member of

the interdisciplinary group must be performed by a Doctor of Medicine or osteopathy or

a nurse practitioner for the Medicaid only member.

Revenue Code 657 is used on a line item to indicate the physician’s or nurse

practitioner’s hands-on visit to the Medicaid member. The hospice provider submits the

UB-04 claim using Revenue Code 657 on the line item for the professional service of

the hospice physician/nurse practitioner, the appropriate HCPCS code for the applicable

time spent (one [1] unit allowed) and the date of the service. Note: non-hospice

physicians, e.g. consultants, should bill on the CMS-1500 for the member’s

professional services that are not related to the terminal illness.

The allowed procedure codes for use with Hospice Revenue Code 657 are listed below:

903.3.1. Procedure Code 99212

Office or other outpatient visit for the evaluation and management of an

established patient, which requires at least 2 of these 3 key components:

903.3.1.1. A problem focused history.

903.3.1.2. A problem focused examination; Straightforward

medical decision making.

903.3.1.3. Counseling and/or coordination of care with other

providers or agencies are provided consistent with the

nature of the problem(s) and the patient’s and/or

family’s needs.

Usually, the presenting problem(s) are self-limited or

minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family

903.3.2. Procedure Code 99213

Office or other outpatient visit for the evaluation and management of an

established patient, which requires at least 2 of these 3 key components:

903.3.2.1. An expanded problem focused history; An expanded

problem focused examination; Medical decision making

of low complexity.

Counseling and/or coordination of care with other

providers or agencies are provided consistent with the

nature of the problem(s) and the patient’s and/or

family’s needs.

Usually, the presenting problem(s) are of low to

moderate severity. Physicians typically spend 15

minutes face-to-face with the patient and/or family.

903.3.3. Procedure Code 99214

Office or other outpatient visit for the evaluation and management of an

established patient, which requires at least 2 of these 3 key components:

903.3.3.1. A detailed history.

903.3.3.2. A detailed examination.

903.3.3.3. Medical decision making of moderate complexity.

903.3.3.4. Counseling and/or coordination of care with other

providers or agencies are provided consistent with the

nature of the problem(s) and the patient’s and/or

family’s needs.

903.3.3.5. Usually, the presenting problem(s) are of moderate to

high severity. Physicians typically spend 25 minutes

face-to-face with the patient and/or family.

903.3.4. Procedure Code 99215

Office or other outpatient visit for the evaluation and management of an

established patient, which requires at least 2 of these 3 key components:

903.3.4.1. A comprehensive history.

903.3.4.2. A comprehensive examination.

903.3.4.3. Medical decision making of high complexity.

Counseling and/or coordination of care with other

providers or agencies are provided consistent with the

nature of the problem(s) and the patient’s and/or

family’s needs.

Usually, the presenting problem(s) are of moderate to

high severity. Physicians typically spend 40 minutes

face-to-face with the patient and/or family.

903.4. Hospice providers (Provider Contract, COS 690) who have experienced these claims

denials will be able to submit new claims to replace those that denied using the correct

procedure code(s). Hospice Providers will have thirty (30) days from the posting date of

this notice to do so.

Following the thirty (30) day period of resubmission, Georgia Medicaid will perform a

Mass Adjustment to reprocess the new claims to override timely filing only. Only those

claims submitted cleanly, and which only deny for timely filing only will successfully

adjudicate in this one-time mass adjustment to allow hospice claims for physician

services.

See Chapter 1000, Section 1002 for additional payment of physician services not

related to the above.

The following services performed by hospice physicians are included in the

reimbursement rates:

903.4.1. General supervisory services performed by the medical director. Hospice

services must be related to the terminal diagnosis of the member and are

professional (hands-on) in nature for a physician and/or nurse

practitioner identified as the member’s attending physician at the time of

election. These services are separately billable by the hospice and can be

included on the hospice claim that is submitted to Medicaid.

903.4.2. Participation in the establishment of plans of care, supervision of care

and services, periodic review and updating of care plans and

establishment of governing policies by the physician member or nurse

practitioner of the interdisciplinary group. Administrative activities, e.g.

care-planning, face- to-face certifications, etc., are not separately billable

as these services are included in the per diem rate.

903.4.3. Hospice Providers must maintain written records for

Medicaid/PeachCare for Kids members as necessary to disclose fully the

extent of services provided and the medical necessity for the provision of

such services:

903.4.3.1. Physician Progress Notes must remain in the patient’s

medical record whether services are furnished directly or

under arrangements made by the hospice agency.

903.4.3.2. Progress Notes must include complete documentation of

the hands-on services and events including evaluation,

treatments, problems/needs identified by the individual

or family member/caregiver, etc., to support billing.

903.4.3.3. Providers must comply in a timely fashion with all

requests for records, information, and documentation

made by the Division. For additional information, see

Part 1 Medicaid Policy, Section 106, R) and S).

903.4.3.4. See Chapter 1000, Section 1002 for additional payment

of physician services not related to the above.

903.5. Counseling Services provided to the terminally ill individual and the family members or

other persons caring for the individual at home. Counseling, including dietary

counseling, may be provided both for training the individual’s family or other caregiver

to provide care, and for helping the individual and those caring for him or her to adjust

to the individual’s approaching death.

903.6. Short-Term Inpatient Care provided in a participating hospice inpatient unit or a

participating hospital that meets the special hospice standards regarding staffing and

patient areas. General inpatient care may be required for procedures necessary for pain

control or acute or chronic symptom management which cannot be provided in other

settings.

903.7. Inpatient Respite Care is short-term inpatient care required to provide relief from care

for the individual’s family or other persons caring for the individual at home. Respite

care may be provided only on an occasional basis and may not be reimbursed for more

than five (5) consecutive days at a time. Respite care may not be provided when the

hospice individual resides in the nursing facility on a permanent basis.

Services provided in the facility must conform to the hospice agency’s Plan of Care.

The hospice agency must have a contract with the inpatient facility to provide respite

care delineating the roles of each provider in the hospice agency’s Plan of Care.

However, the hospice agency is the professional manager of the individual’s care,

despite the physical setting of that care or the level of care. Documentation in the

individual’s record must indicate the reason respite care was necessary. For more than

one respite care admission in a short amount of time, the documentation must clearly

identify reasons multiple admissions were necessary.

See Chapter 1000, Section 1001 for additional coverage regarding inpatient respite care.

903.8. Medications/Pharmacy

Medicaid members who elect to enroll in the Hospice program receive all care related

to their terminal illness from the hospice. Prescriptions filled for these members relating

to the terminal illness are to be paid by the hospice and should not be billed to the

Medicaid drug program. Pharmacy hospice claims do not require paper or attachments

and can be billed through POS effective 10/1/2000. However, should the Medicaid

hospice patient require covered drugs that do NOT relate to the terminal illness, these

prescriptions may be billed to Medicaid with some restrictions.

Effective 03/23/2010, children less than 21 years of age will no longer be required to

forego curative care when electing hospice. They may concurrently receive palliative

and curative treatment related to the terminal illness. All palliative treatment is to be

provided by the hospice provider through hospice services reimbursed by Medicaid.

Pharmacy services prescribed as curative treatment for children less than 21 years of

age will also be paid by Medicaid when eligibility for concurrent care criteria is met.

Providers wishing to prescribe drugs for curative treatment from the list of medications

below should use the pharmacy services PA process to request an exception.

DCH considers the following drugs palliative in nature and therefore ineligible for

coverage in the outpatient pharmacy program for hospice members. These include but

are not limited to:

903.8.1. analgesics antibiotics* antidepressants* anti- emetics antifungals

antihistamines for sleep anxiolytics

903.8.2. appetite stimulants folic acid, multivitamins, iron hematopoietic (Procrit,

Epogen, etc.)

903.8.3. HIV drugs

903.8.4. hypnotics interferons laxatives megestrol anti-migraine drugs muscle

relaxants non-steroidal anti- inflammatory agents oncology drugs

sedatives

903.8.5. stool softeners

*Approval on a case-by-case basis.

903.9. Medical Appliances and Supplies

Appliances may include covered durable medical equipment as well as other self-help

and personal comfort items related to the palliation or management of the patient’s

terminal illness. Equipment is provided by the hospice for use in the patient’s home

while he or she is under hospice care. Medical supplies include those that are part of the

written plan of care and relate to the terminal illness or conditions related to the

terminal illness.

903.10. Home Health Aide Services for personal support

Home Health Aide services will be performed by individuals who have successfully

completed Home Health Aide training and competency evaluation.

Training at a minimum must include classroom and practical training totaling at least 75

hours of practical training that must include at least 16 hours devoted to supervised

practical training.

Home Health Aides may provide personal care services. Services may include bathing,

grooming, dressing, and performance of household services necessary to maintain a

safe and sanitary environment in areas of the home used by the patient. Household

service may include changing the individual’s bed, light cleaning, and laundering

essential to the comfort and cleanliness of the patient. Aid services must be provided

under the general supervision of a registered nurse.

A registered nurse (RN) must visit the home at least every 2 weeks when aide services

are provided. The visit must include an assessment of the aide services (This shall mean

observation of the aide). Documentation of the supervisory visit by the RN must be

filed in the individual’s medical record.

903.11. Physical Therapy, Occupational Therapy and Speech-Language pathology services

provided for purpose of symptom control or to enable the individual to maintain

activities of daily living and basic functional skills.