La. Medicaid Services Manual ch. 24 (Hospice) § 24.10

Reimbursement requires compliance with all Medicaid requirements. Hospice providers bill for

room and board using the standard 837 Institutional (837I) electronic claim transaction or the

hardcopy UB-04 Form, regardless of the date of service. All supplemental billing must also be

submitted electronically using the 837I format or on the UB-04 hard copy claim form. The 837I is

the preferred method of claim submission.

Medicaid Requirements for Enrolling Ordering, Prescribing and Referring

Providers

The Affordable Care Act (ACA) requires physicians or other practitioners who order, prescribe,

or refer items or services to Medicaid beneficiaries to enroll in the Medicaid Program, even when

they do not submit claims to Medicaid. ACA requirements are designed to ensure that items or

services for Medicaid beneficiaries originate from appropriately licensed providers who have not

been excluded from Medicare or Medicaid.

Individuals who order, prescribe, or refer items or services for Medicaid beneficiaries, but choose

not to submit claims to Medicaid, are referred to throughout this notice as “Ordering, Prescribing,

and Referring (OPR) providers.”

Professional and Institutional Billing Providers should begin notifying any individuals who

you report on fee-for-service (FFS) claims as an ordering, prescribing or referring provider

that they must enroll with Louisiana Medicaid.

OPR providers must understand the implications of failing to enroll in Medicaid. If you are an

OPR provider, then the individuals and facilities who bill services for Medicaid beneficiaries based

on your order, prescription, or referral will not be paid for those items or services unless you enroll

in Medicaid. Timely filing claim requirements may be impacted while waiting for providers to be

enrolled; therefore, applications should be submitted as quickly as possible.

Effective with claims using dates of service on or after September 1, 2016, the Louisiana

Medicaid Program will deny FFS claims that use referring providers who are not enrolled

as of the date of service. Providers should monitor the Louisiana Medicaid website for future

information specific to ordering providers.

Louisiana Medicaid has established edits for issues with prescribing providers.

Enrollment

Practitioners currently enrolled as participating providers in FFS Medicaid Program are not

required to enroll separately as an OPR provider.

Diagnosis Codes

All billers should use the correct diagnosis codes (International Classification of Diseases (ICD)-

10-CM or its successor) that supports medical necessity and are appropriate for use with hospice

related conditions.

Revenue Codes

Bill for hospice services provided according to the level of care (LOC) and location of the

beneficiary for each day of the hospice election period.

Frequency of Billing

The UB- 04 form should be submitted each month after the month for which services were

provided. Providers do not have to split a claim for a month’s dates of service around the

beneficiary’s election period dates. However, a claim cannot span more than two election periods.

The provider should split bills if they span the effective date of the annual increase in the payment

rates for hospice care services.

Claims Submission for Beneficiaries Residing In the Home

Hospice providers only bill for direct hospice services when a beneficiary resides in the home. If

the beneficiary is dual eligible with Medicare Part A, a bill should not be submitted to Medicaid

because Medicare Part A reimburses hospice services at 100 percent.

Claims Submissions for Beneficiaries Residing In a Long Term Care Facility

Hospice providers’ bill for both direct hospice services and room and board when a beneficiary

resides in a nursing f acility unless the beneficiary is dual eligible with Medicare Part A. If the

beneficiary is dual eligible with Medicare Part A, then Hospice providers bill only for room and

board. Because Medicare Part A reimburses hospice services at 100 percent, no bill for direct

hospice services or room and board in a skilled nursing facility (SNF) should be submitted to

Medicaid.

The room and board rate of reimbursement is 95 percent of the per diem rate that would have been

paid to the facility for that beneficiary in that facility under the Medicaid State Plan, except that

any patient liability income (PLI) determined by the Bureau of Health Services Financing (BHSF)

will be ded ucted from the payment amount. It is the responsibility of the nursing facility or

intermediate care facilities for individuals with intellectual d isabilities ( ICF/IID) to collect the

beneficiary’s PLI.

Hospice providers may only bill Medicaid once per calendar month for nursing facility or ICF/IID

room and board.

Medicaid Only

Providers should bill for routine or continuous home care and bill the rate to cover room and board

as appropriate. The Medicaid parish office will advise the resident and nursing facility or ICF/IID

of the resident’s PLI. Medicaid will deduct the resident’s PLI from the amount to be reimbursed

to the hospice. The hospice provider is to pay the facility according to the contract agreement

subject to adjusted claims the nursing facility may encounter as a result of case mix methodology.

Medicaid and Medicare (Dual Eligible)

Providers should bill for the room and board rate for each day the resident is in the facility.

Providers should bill Medicare for routine or continuous home care, as appropriate. The hospice

provider is to pay the facility according to the contract agreement subject to adjusted claims the

nursing facility may encounter as a result of the case mix methodology.

NOTE: General inpatient care and room and board cannot be reimbursed for the same

beneficiary for the same covered day of service.

Claims Submissions for Schedule (Room and Board ONLY)

Claims for room and board are processed according to a predetermined schedule set by the

Louisiana Department of Health (LDH) and is updated every calendar year. This schedule includes

deadlines for initial monthly claim submissions as well as deadlines for monthly supplemental

claim submissions.

NOTE: Providers who bill hardcopy claims should continue to submit the initial monthly UB-04

forms in one package.

Levels of Care Billing

Payment rates are determined at one of the four levels for each day of a beneficiary’s hospice care.

Providers should use the following chart to determine the appropriate level for billing:

Revenue

Code

Units of

Service Level of Care Required Documentation

651

659

24-Hours

(1 day)

1unit=15

minutes

Routine Home Care

The routine home care rate is paid for each day the

beneficiary is under the care of the hospice and not

receiving one of the other categories of care. This

rate is paid without regard to the volume or intensity

of routine home care services provided on any given

day. It is also paid when the beneficiary is receiving

hospital care for a condition unrelated to the

terminal condition.

This rate is also paid in the following situations if

the beneficiary is:

1. In a hospital that is not contracted with the

hospice;

2. In a hospital for care unrelated to the

terminal condition;

3. Is receiving outpatient services in the

hospital; or

4. For the day of discharge from general

inpatient care or respite LOC.

Service Intensity Add-On Rate

The service intensity add-on (SIA) rate will be

reimbursed only when billed in conjunction with

the Routine Home Care code. Services must be

rendered by a registered nurse (RN) or a social

worker only. Bill codes G0299 ( RN) or G0155

(social worker) for each day a visit is made within

the last seven days of a person’s life. Claims must

be submitted in hardcopy with documentation and

progress notes justifying the intensity and number

of visits. Payment will be reimbursed in 15 minute

increments (one unit). The maximum total billed

per day cannot exceed four hours.

The hospice must develop and

maintain a plan of care (POC) for

the beneficiary.

The beneficiary’s clinical record

should include any updates to the

POC and changes to the

beneficiary’s condition between

the updates.

The beneficiary’s clinical record

should include all disciplines’

progress notes

(daily/weekly/monthly) that

record the type and frequency of

the services provided to the

beneficiary.

The date of service must have been

previously submitted to Medicaid

and/or the appropriate health plan

and is already on file before

payment can be made on the SIA

rate.

Revenue

Code

Units of

Service Level of Care Required Documentation

652 1 Hour Continuous Home Care

A minimum of eight hours of care must be provided

during a 24 -hour day, which begins and ends at

midnight. This care need not be continuous, 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. The

continuous home care rate is divided by 24 hours in

order to arrive at an hourly rate.

Documentation must:

Clearly document reason for

continuous care.

List the dates of service that the

beneficiary was under continuous

home care.

Record hour by hour and day by

day what services were provided,

the beneficiary’s condition, and

the type of personnel providing the

continuous care.

655 1 Day Inpatient Respite Care

The payment for respite care may be made for a

maximum of five consecutive days in an election

period at a time including the date of admission, but

not counting the date of discharge alive.

Payment for the sixth and any subsequent day is to

be made at the routine home care rate.

Documentation must:

Clearly indicate the facility in

which the beneficiary is receiving

the respite LOC, the dates that the

beneficiary was at respite LOC,

and why the respite care was

necessary.

NOTE: The total number of days

allowed is subject to the inpatient

care cap. See provider

responsibilities for more

information.

Revenue

Code

Units of

Service Level of Care Required Documentation

656 1 Day General Inpatient Care

For the date of admission to the contracted inpatient

facility, the general inpatient rate is to be paid.

For the day of discharge from the contracted

inpatient unit, the appropriate routine home care

rate is to be paid unless the beneficiary dies as an

inpatient.

Upon death, the general inpatient rate is to be paid

for the discharge date for the beneficiary admitted

to the contracted facility.

The provider should bill revenue code 656 for

beneficiaries admitted to a contracted facility.

The hospice may not bill the general inpatient

rate for days that the beneficiary is in a non -

contracted facility or in a facility for a reason

unrelated to the terminal condition or in an

inpatient facility where the facility is considered

the beneficiary’s temporary or permanent

residence/home. The hospice bills routine home

care rate for these days.

Documentation must include:

The name of the facility in which

the beneficiary is receiving the

general inpatient LOC;

The dates the beneficiary was at

the general inpatient LOC;

A clear explanation of the reason

why the admission was necessary;

The beneficiary’s condition during

the inpatient stay; and

The physician’s discharge

summary and any hospice

interdisciplinary notes during the

beneficiary’s inpatient stay.

NOTE: General inpatient care

days are subject to limitation s.

General inpatient care may be

required for procedures necessary

for pain control or acute or chronic

symptom management that cannot

feasibly be provided in other

settings. Once the symptoms are

under control, routine home care

must be billed. The total number of

days allowed is subject to the

inpatient care cap. See provider

responsibilities for more

information.

657 1 day Physician Services

For use when physician professional services are

being provided to hospice beneficiaries; and the

hospice is responsible for reimbursing the

physician.

The physician can be an employee of the hospice, a

volunteer, or a consultant.

Document all beneficiary

encounters.

Third Party Liability

Medicaid, by law, is intended to be the payer of last resort. Therefore, other available third- party

resources, including private insurance, must be used before Medicaid pays for the care of a

Medicaid beneficiary.

If probable third-party liability (TPL) is established at the time the claim is filed, Medicaid will

deny the claim and return it to the provider for determination of TPL for most Medicaid services.

In these cases, the Bureau then pays the balance of the claim to the extent that payment is allowed

under Medicaid’s fee schedule after the third party’s payment. Early a nd periodic screening,

diagnostic, and treatment ( EPSDT) diagnostic and screening services are exempt from this

requirement. For these services, Medicaid will pay the claim up to the maximum allowable

amount. However, these exceptions do not include treatment or therapy that must be billed to the

beneficiary’s third-party carrier (if applicable) prior to billing Medicaid. When Medicaid is billed,

hard copy of the claim must be filed with the third-party carrier’s Explanation of Benefits (EOB)

attached to the claim form.

For beneficiaries with private insurance, hospice providers should still submit requests for hospice

services timely to the hospice Prior Authorization Unit (PAU) in order for the appropriate reviews

and future accurate reimbursement to take place.

Exception: The only time Medicaid is considered as primary is when the beneficiary has health

coverage through Indian Health Services. In these cases, claims should be billed to Medicaid first,

then to Indian Health Services.

Timely Filing Guidelines

To be reimbursed for services rendered, all providers must comply with the filing limits set by the

Medicaid Program. Refer to Chapter 1 of the Louisiana Medicaid provider manual, General

Information and Administration. The manual can be accessed on the internet at

www.lamedicaid.com.