Iowa Medicaid Hospice Provider Manual ch. III § D.2.b

Medicaid provides a daily reimbursement for every day that a member is

hospice eligible. The daily rate is one of the four categories of care.

The categories of care are not based on the qualifications of the staff

providing services. There may be a number of hospice staff who may

support a hospice member during a day. Hospice staff supporting a

member could include, but not limited to, a:

• Nurse practitioner (NP),

• Registered nurse,

• Hospice aide,

• Medical social worker,

• Clergy,

• Volunteer, and

• Physical therapist.

As an example, the medical expertise of the NP was required for a

member. The NP provided both direct and indirect services for a total of

six hours. The daily hospice reimbursement would not increase because

of the NP qualifications, medical expertise or the NP’s time. The daily

hospice reimbursement remains a fixed rate.

All hospice services must be performed by appropriately qualified

personnel; but it is the comprehensive, inclusive nature of multiple

services of the hospice program that determines the daily category

reimbursement rather than the qualifications of any category of staff

that provides services.

Each of the four levels of care has a predetermined reimbursement rate.

Payment is based on the geographic location at which the service is

furnished. For hospice services provided in the member’s residence,

geographical region is based on the member’s county of residence. For

hospice services provided in an inpatient setting, geographical region is

based on the county of the enrolled billing hospice provider. The

metropolitan statistical area (MSA)/rural state code must be included on

the claim for these revenue codes. The four categories of hospice are:

• Routine Home Hospice Care (Revenue Code 651)

The hospice will be paid the Routine Home Care (RHC) rate for each

day the member is at home, under the care of the hospice, and not

receiving continuous home care.

A routine rate is paid without regard to the volume or intensity of

routine home care services provided on any given day.

A nursing facility may be considered the home for a member who

has elected the hospice benefit.

RHC is paid one of two RHC rates based on the following:

1. The day is billed as a RHC level of care.

2. If the day occurs during the first 60 days, the RHC will be equal

to the RHC “High” rated.

3. If the day occurs during days 61 or later, the RHC rate will be

equal to the RHC “Low” rate.

4. For a hospice member who is discharged and readmitted to

hospice within 60 days of that discharge, their prior hospice days

will continue to follow the member in determining the “High” or

“Low” rate.

5. For a hospice member who has been discharged from hospice

care for more than 60 days, a new period of hospice will apply

and be paid at the “High” rate.

These rates are calculated on the annual hospice rates established

under Medicare.

• Service Intensity Add-on (SIA)

A hospice claim will be eligible for a SIA payment if the following

criteria are met:

1. The day is billed as a RHC level of care day: the day occurs

during the last seven (7) days of life and the member is

discharged as deceased;

40 Expired at home

41 Expired in a medical facility

42 Expired place unknown

2. Direct member is provided by a Registered Nurse (RN) or social

worker that day for at least 15 minutes and up to four hours

total.

3. The service is not provided by a social worker via telephone.

• Continuous Home Hospice Care (Revenue Code 652)

Continuous home care is covered when it is provided to maintain a

member at home during a period of medical crisis. A period of crisis

is a period of time when a member requires continuous care which is

primarily nursing care to achieve palliation or management of acute

medical symptoms.

Nursing care must be provided by either a registered nurse or a

licensed practical nurse. A nurse must be providing care for more

than half of the care given in an hour period. If less skilled care is

needed on a continuous basis to enable the person to remain at

home, this is covered as routine home care.

The amount of payment is determined based on the number of hours

of continuous care furnished to the member on that day. A

minimum of eight hours must be provided during a 24-hour period

which begins and ends at midnight before the continuous home care

rate can be billed.

This care need not be provided all at once, i.e., four hours could be

provided in the morning and another four hours provided in the

evening of that day. Homemaker and aide services may also be

provided to supplement the nursing care.

• Inpatient Respite Care (Revenue Code 655)

Respite inpatient care is short-term inpatient care provided to the

member only when necessary to relieve the family members or other

persons caring for the member at home. Respite care is not paid

when the hospice member is residing in a nursing facility.

The hospice is paid at the inpatient rate for a maximum of five days

at a time when the member is in an approved inpatient facility.

Payment is made for the date of admission but not for the date of

discharge. The discharge day for inpatient respite care is billed as

routine home care or continuing home care, unless the member is

discharged as deceased. When the member is discharged as

deceased, the inpatient respite care rate is billed.

• General Inpatient Care (Revenue Code 656)

General inpatient care is provided in periods of acute medical crisis

when the member is hospitalized for pain control or acute or chronic

symptom management. None of the other fixed payment rates

(e.g., routine home care) are applicable for a day on which the

member receives hospice inpatient care, except for the day of

discharge from an inpatient unit.

The discharge day for general inpatient care is billed as routine home

care or continuous home care, unless the member is discharged as

deceased. When the member is discharged as deceased, the general

inpatient rate is billed.

• Physician Services (Revenue Code 657)

Direct physician care provided to a Medicaid member by a hospice

employee or any contracted physician is billed to Medicaid by the

hospice agency. Reimbursement will be in accordance with the

Medicaid physician payment schedule for Medicaid fee-for-service

members. On the UB-04 billing form, include Revenue Code 657

and the CPT-4 code that identifies the physician service provided.

NOTE: The bulleted physician services below are not billed using

Revenue Code 657. Please refer to Nonreimbursable Hospice

Physician Payment for further clarification:

• General and supervisory physician services provided by

physicians employed by or under contract with the hospice

provider

• Attending physician services

• Voluntary physician services