N.C. Medicaid Clinical Coverage Policy No. 3D § 8.0

Original Effective Date: August 1, 1984

History:

Date

Section or

Subsection

Amended

Change

All Sections and

Attachment(s)

12/01/2006

Sections 2, 3, 5

A special provision related to EPSDT was added.

04/01/2007

Subsection 7.1.2.1

Removed statement that Medicaid reimburses for

coinsurance on hospice-covered drugs and respite days

04/01/2007

Section 2.6, 3.0,

4.0, and 5.0

EPSDT information was revised to clarify exceptions to

policy limitations for beneficiaries under 21 years of age

05/01/2007

Attachment A

Added UB-04 as an accepted claims form.

08/01/2007

Section 6.0

Changed the name of Division of Facility Services

(DFS) to Division of Health Service Regulation

(DHSR).

08/01/2007

Subsection 2.3 and

Attachment C

Medicare-AID beneficiaries are not eligible for

Medicaid-covered hospice services.

08/01/2007

Attachment A, letter

E

Added revenue code 658.

12/01/2009

(effective

12/02/2008)

Throughout

Updated to include DMA standard statements and

incorporate requirements in changes to 42 CFR 418 and

CMS Conditions of Participation, issued 10/1/2008,

effective 12/2/2008.

05/11/2010

Subsection 2.2

Changed reference from Subsection 5.8.2 to Subsection

5.1.2

07/01/2010

Throughout

Session Law 2009-451, Section 10.31(a) Transition of

NC Health Choice Program administrative oversight

from the State Health Plan to the Division of Medical

Assistance (DMA) in the NC Department of Health and

Human Services.

06/01/2011

Subsections 1.1.12,

5.7, 7.3.2, 7.3.2.2

Updated information on hospice and long-term care to

include ICF/MR and related MR-2

06/01/2011

Subsection 5.4.2,

5.4.3

Refer to Attachment C

06/01/2011

Subsection 5.4.3

Added information on the Face-to-Face Encounter

requirements.

06/01/2011

Subsection 5.6.2

Added The waiver of curative services is not applicable

to beneficiaries under 21 years old. Refer to Subsection

5.6.3.

06/01/2011

Subsection 5.6.3

Added Provision of Hospice Care for Children Under 21

Years Old. Under Provision of Hospice Care for

Children Under 21 Years Old added sentence to include

Date

Section or

Subsection

Amended

Change

the complete hospice package having to be provided

with the addition of a curative service

06/01/2011

Subsection 5.6.3

Clarified wording on concurrent care

06/01/2011

Subsection 7.2

Added Patient Self Determination Act information

06/01/2011

Attachment A

Updated to standard DMA policy language

06/01/2011

Attachment C

Added Attachment C

11/01/2012

Throughout

Technical changes to merge Medicaid and NCHC

current coverage into one policy.

11/01/2012

Subsections 5.1, 5.2

Addition of prior approval requirement prior to fifth and

each subsequent benefit period.

11/01/2012

Subsection 1.1.10

Clarified that general inpatient care can also be provided

in a hospice inpatient facility

11/01/2012

Subsection 5.7.2

Added reference to Outpatient Pharmacy policy

regarding billing for medications for hospice

beneficiaries.

11/01/2012

Subsection 5.10

Clarification that in the case of a patient transfer

between hospice agencies, only one agency can be paid

per day.

11/01/2012

Subsection 7.5

Changes two weeks’ requirement for plan of care review

to 15 calendar days

11/01/2012

Attachment A

Deleted statement about non-contracting hospice

agencies. Changes place of service back to “Not

Applicable”

11/01/2012

Attachment C

Changed language referring to “nurse practitioners” to

“Medicare officially recognized non-physician

providers” Changes three days’ requirement in face to

face encounter to seven days

07/01/2013

Subsection 5.2

Added “Prior approval is requested by the hospice

medical director or beneficiary’s attending physician via

NC Tracks, PA Type A-10 Hospice, at least ten days

before the end of the current certification period. If

prior approval is denied, the beneficiary will be notified

of his or her appeal rights.”

07/01/2013

Subsection 5.2

Deleted “Prior approval is requested by the hospice

medical director or beneficiary’s attending physician as

follows:

a. The physician submits the request in writing

using the N.C. Medicaid Hospice Prior Approval

Authorization Form (NC DMA-3212), which can be

obtained from the DMA website (Refer to

Attachment D).

b. The physician provides information detailing

the complications of the pregnancy (for MPW

beneficiaries only), medical necessity for hospice

Date

Section or

Subsection

Amended

Change

services, the potential impact if the service is not

provided, the frequency of visits, and the anticipated

duration of services.

c. The completed form is sent to DMA’s

designated fiscal agent along with the

accompanying documentation listed on the form.

The prior approval request is submitted by mail at least

ten days before the end of the current certification

period. The fiscal agent will respond to the hospice

provider via fax within five business days. If prior

approval is denied, the beneficiary will also receive via

mail notification with appeal rights.”

07/01/2013

Attachment D

Deleted outdated information to reflect current process

with fiscal agent.

10/01/2015

All Sections and

Attachments

Updated policy template language and added ICD-10

codes to comply with federally mandated 10/1/2015

implementation where applicable.

01/01/2016

All Sections and

Attachments

The current policy will allow adult IHC and

Residential PCS beneficiary to receive Hospice

services and PCS services concurrently when they meet

eligibility requirements for both programs. (Refer to

note in

01/15/2018 Amendment Section 8.0)

06/15/2016

Section 8.0

Notation for 10/1/2015 regarding ICD-10 update

returned to the table. This was inadvertently dropped

out during the policy revision process of 01/01/2016.

No effect on coverage or scope of policy, so no change

made to Amended Date.

01/15/2018

All Sections and

Attachments

Clinical Policy 3D, Hospice Services reorganized,

rewritten, and services clarified.

01/15/2018

Section 5.0

Subsection 5.1, 5.2,

5.2.2

Modified the clinical review timeframe for 300 days

(prior to the 5th certification period) to 180 days (prior

to the 3rd certification period).

01/15/2018

Section 5.0

Subsection 5.7

Incorporated the requirement for the electronic

submission of the Election Statement as a component

of the Prior Approval Request for the 1st Certification

Period.

01/15/2018

Attachment A

Claims Related

Information;

Subsection H

1.1 Routine Home

Care

1.2 Two Tier Rate

1.3 Service

1.1 Routine Home Care

Hospice shall comply with 42 CFR §418.302 Payment

procedures for hospice care.

1.3 Service Intensity Add-On (SIA)

The SIA payment is in addition to the per diem

RHC rate when all the following criteria are met: a.

The day is an RHC level of care day;

Date

Section or

Subsection

Amended

Change

Intensity Add-On

(SIA)

b. The day occurs during the last 7 days of the

patient’s life;

c. The patient is discharged expired; and

d. Direct patient care is furnished by a registered

nurse

(RN) or clinical social worker (SW) qualifying day.

The SIA payment is based on the Continuous Home

Care (CHC) hourly payment rate multiplied by the

amount of direct care provided by an RN or social

worker during the last 7 days of life in increments of 15

minutes, up to 4 hours per day.

New G-codes will be used to identify the SIA provider

(RN or Social Worker) in conjunction with Revenue

Code 0235

NCTracks does not allows Hospice providers to bill

status code 20 to denote the death of Hospice

beneficiary. Therefore, valid discharge codes denoting

death of the patient for hospice claims were created.

•

40 (expired at home),

•

41 (expired at medical facility),

42 (expired place unknown).

01/15/2018

Section 8

Removed statement from the January 1, 2016

amendment “These revisions had no effect on scope of

coverage.” Replaced with, “The current policy will

allow adult IHC and Residential PCS beneficiary to

receive Hospice services and PCS services concurrently

when they meet eligibility requirements for both

programs.”

02/01/2018

All Sections and

Attachments

Policy posted on this date, with an Amended Date of

January 15, 2018

12/01/2019

Section 1.1.2

Hospice care

Added word Social Security

12/01/2019

Section 1.1.5

Clarified wording-changed “and” to “or”

12/01/2019

Subsection 3.2.1 -

Specific criteria

covered by both

Medicaid and

NCHC

•Removed citations that were not related to Covered

Services

•Citations are listed is subsection 6.1 Provider

Qualifications and Occupational Licensing Entity

Regulations

12/01/2019

Subsection 3.2.1 -

Specific criteria

covered by both

Medicaid and

•According to 42 CFR §418.202 - Covered services (i)

Added verbiage was missing from Citation to complete

sentence “as reasonable and necessary for the palliation

and management of the patient's terminal illness and

Date

Section or

Subsection

Amended

Change

NCHC –(k)

related conditions and for which payment may

otherwise be made under Medicaid”.

12/01/2019

Subsection 3.2.1 -

Specific criteria

covered by both

Medicaid and

NCHC last

paragraph

Completed sentence with the time frame which

Medicaid and NCHC ambulance service can occur

“which occur after the effective date of election”.

12/01/2019

Section 5.2.2.2

Subsection e (removed “Palliative Performance Scale”)

Removed (f)

Adding “Hospice Assessment” Tool

12/01/2019

Section 5.2.2.2

Note: section

Removed - “using Type: A10-Hospice”

Added wording “or physician assistant”

Added- Refer to Section 7.8

12/01/2019

5.2.2.3 Nursing

Facility and 5.2.2.4

Long Term Care –

DHB adding to section 5.2.2.3 Nursing Facility

“Note: Hospice agencies verify Nursing facility or

ICFIID long-term care approval in NC Tracks to ensure

the approval was obtained prior to seeking

reimbursement. Hospice providers should provide

documentation referencing place of origin verifying the

FL-2 in beneficiary medical records.

DHB adding to section 5.2.2.4 Long Term Care

“Note: Hospice agencies verify the nursing facility or

ICF/IID level of care long-term care approval in NC

Tracks to ensure the approval was obtained prior to

seeking reimbursement.

Hospice providers should provide documentation

referencing place of origin verifying the FL-2 or IID-2

in beneficiary medical records”.

12/01/2019

Subsection 5.6.1

Filling an election

statement

Verbiage omitted from 42 CFR § 418.28(a). If

beneficiary is physically or mentally incapacitated, his

or her representative (as defined in §418.3) may file the

election statement.

Date

Section or

Subsection

Amended

Change

12/01/2019

Subsection 5.6.5 Re-

election of hospice

benefits

Verbiage omitted from 42 CFR § 418.28 “(or his or her

representative if the beneficiary is mentally or

physically incapacitated)”.

12/01/2019

Subsection 5.12.4-

Note: section

Removed – “with each PA entry beginning with the 3rd

and subsequent benefit periods”

Removed – “the Approval Status Inquiry form or”

Clarified wording - DMA providers” to” fax a copy of

the NC Tracks Web Submitted Request for HOSPICE

Prior Approval Confirmation Page to NC Medicaid

“with each PA entry”. “The confirmation page is to be

faxed to” 919-715-9025.

12/01/2019

Section 7.3.2.2

Removed - reference to Subsection 5.13

DHB adding

“According to 10A NCAC 23E.0210PATIENT

LIABILITY (d) - The county department of social

services shall notify the client, the institution and the

state of the amount of the monthly liability and any

changes or adjustments.

Hospice agencies verify the PML amounts in NC Tracks

prior to billing for long term care services. Providers

may experience discrepancies with the beneficiary’s

current eligibility which prevents them from billing for

long term care services.

The discrepancies may include but are not limited to:

No patient monthly liability listed on the

beneficiary’s file in NCTracks

No DMA-5016 received by the provider

Dates or amounts listed on the DMA-5016 do not

align with the dates or amounts on the beneficiary’s

eligibility detail in NCTracks

Providers experiencing any discrepancies must contact

the DSS in the beneficiary’s county of residence to have

the information corrected.

Those with questions about PML should contact the

N.C. Medicaid Contact Center at 1-888-245-0179.

Date

Section or

Subsection

Amended

Change

12/01/2019

Section 7.3.2.2

Added - “According to 10A NCAC 23E.0210”

12/01/2019

Attachment A:

Claims-Related

Information Section

C. Code -0235

Added: -

Modifier: Adding Post-mortem Visits (PM) modifier.

Hospice shall report visits and length of visits (rounded

to the nearest 15- minute increments), that occur on the

date of death, after the patient has expired for nurses,

aids, social workers, and therapists who are employed

by the hospice. This requirement is applicable for all

levels of care (with the exception of GIP provided in a

hospice inpatient facility).

12/01/2019

Attachment A: D,

Modifiers

Added:

Post-Mortem (PM) visits reporting that occur after

death and on date of death. Includes hospice-employed

nurses, aids, social workers and therapists; regardless of

level of care, or site of service.

Billing

Code appropriate visit revenue code + HCPCS for the

discipline + PM Modifier + Units of 15 minutes

increments + Charges + Service date.

Note: Visits subsequent to date of death are not reported

using the PM modifier. Date of date is defined as the

date of expiration reported on the official Certificate of

Death. Hospice shall report hospice visits that occur

before the date of death on a separate claim line from

those which occur after the death.

12/01/2019

Attachment A:H, 6

“Medicare” changed to “Medicaid”

12/01/2019

Throughout the

3DHospice Policy

Reference 42 CFR citations by “according to”.

12/01/2019

Subsection 5.10

Added “for beneficiaries 21 and under: (Refer to

Subsection 5.11).” to the last sentence of the same

paragraph. To read - The waived Medicaid or NCHC

services are listed below “for beneficiaries 21 and

under: (Refer to Subsection 5.11).”

12/01/2019

Subsection 5.6.4

Added “listed in 42 CFR §418.24 (d)” to read: In the

duration of an election of hospice care, a beneficiary

waives all rights to payments for other Medicaid

services listed in 42 CFR §418.24 (d)

12/01/2019

Attachment C:

Removed - Hospice-PCS Coordination Form

(DMA3165) from policy

12/01/2019

Attachment A

Updated policy template language: “Unless directed

otherwise, Institutional Claims must be billed according

Date

Section or

Subsection

Amended

Change

to the National Uniform Billing Guidelines. All claims

must comply with National Coding Guidelines”.

12/01/2019

Table of Contents

Updated policy template language, “To all beneficiaries

enrolled in a Prepaid Health Plan (PHP): for questions

about benefits and services available on or after

implementation, please contact your PHP.”

08/01/2020

Section 5.12.4

Removed:

Note: NC Medicaid requires providers to fax a copy of

the NC Tracks Web

Submitted Request for HOSPICE Prior Approval

Confirmation Page to NC

Medicaid with each PA entry. The confirmation page is

to be faxed to 919-7159025. NC Medicaid requests that

providers include their name and e-mail address on the

above form.

Added: Note: Hospice providers that fail to provide all

required documents for prior approval to NC Tracks,

may be referred to the Office of Compliance and

Program Integrity (OCPI).

08/01/2020

Policy posted 08/04/2020 with an amended date of

08/01/2020

2/15/2021

Section 5.12.4-final

implementation

Removed:

Note: NC Medicaid requires providers to fax a copy of

the NC Tracks Web

Submitted Request for HOSPICE Prior Approval

Confirmation Page to NC

Medicaid with each PA entry. The confirmation page is

to be faxed to 919-7159025. NC Medicaid requests that

providers include their name and e-mail address on the

above form.

10/01/2022

Section 2.0

Eligibility

requirements:

2.1.2 a

Removed: A beneficiary with Medicaid for Pregnant

Women (MPW) is eligible for hospice services only if

the terminal illness is pregnancy related. Refer to

Date

Section or

Subsection

Amended

Change

Subsection 5.1 for information regarding prior approval

for MPW beneficiaries

10/01/2022

5.1 Prior Approval

Removed:

In addition, Medicaid requires Prior Approval (PA) for

Hospice services when a beneficiary’s physician

determines hospice is needed for a Medicaid for

Pregnant Women (MPW).

10/01/2022

Policy posted with an amended date of 10/01/2022 with

an effective date of 4/01/2022.

04/15/2023

All Sections and

Attachment(s)

Updated policy template language due to North Carolina

Health Choice Program’s move to Medicaid. Policy

posted 4/15/2023 with an effective date of 4/1/2023.

09/01/2023

Attachment A:

Claims-related

information-Hospice

Nursing facility

Room and Board

Remove: “Attending provider”

Replaced with. “Nursing facility where the beneficiary

resides in the Service Facility Provider field.”

Remove: “Attending Provider field of the UB 04 form

or 837I transaction.”

Replaced with. “The Attending Provider should be

placed in the Attending Provider field.”

03/15/2024

Attachment A:

Value Code-a

Remove number 68 and replace with G8