N.C. Medicaid Clinical Coverage Policy No. 3D, Attachment A(C)

Provider(s) shall report the most specific billing code that accurately and completely describes the

procedure, product or service provided. Provider(s) shall use the Current Procedural Terminology

(CPT), Health Care Procedure Coding System (HCPCS), and UB-04 Data Specifications Manual

(for a complete listing of valid revenue codes) and any subsequent editions in effect at the time of

service. Provider(s) shall refer to the applicable edition for the code description, as it is no longer

documented in the policy.

If no such specific CPT or HCPCS code exists, then the provider(s) shall report the procedure,

product or service using the appropriate unlisted procedure or service code.

Revenue Code

Instructions

0651

Routine Home

Care

Routine Home Care is the basic level of care that is provided to support the

beneficiary. It may be provided in a primary private residence, a hospice

residential care facility, or an adult care home. It may also be provided in a

nursing facility if the facility has a contractual arrangement with the hospice

provider. It is billed by the day and is the provider’s basic per diem rate. This

service code is limited to once per day per beneficiary, same or different

provider.

Routine Home Care is not allowed on the same day as Continuous Home or

Inpatient Respite Care. The provider should provide and bill the appropriate

level of service.

0652

Continuous Home

Care

Continuous Home Care is provided during a medical crisis and is billed by

the hour. This level of service is provided when the hospice IDG determines

that continuous care, primarily nursing care, is needed. The care is given to

achieve palliation or management of acute medical symptoms. It can be

provided in the private residence, hospice residential care facility, long term

care facility, adult care home, or nursing facility. The care needed shall be:

•

continuous care for at least 8 hours of the calendar day (the hours may

be split); AND

•

nursing services by an RN or LPN for at least half of the hours of care

in a day.

Homemaker and hospice aide services may be used to supplement the

nursing care. Continuous Home Care is limited to a maximum of 24 units a

day.

Continuous Home Care is not allowed on the same day as Routine Home

Care, Inpatient Respite Care or General Inpatient Care. The provider shall

provide and bill the appropriate level of service.

0655

Inpatient Respite

Care

Inpatient Respite Care is short-term care to relieve family members or other

unpaid caregivers providing care for the beneficiary in the private residence.

It is provided in a hospice inpatient facility or in a hospital or nursing facility

under a contractual arrangement. Hospitals or nursing facilities shall meet the

special hospice standards for staffing and beneficiary areas.

This service can be provided only on an occasional basis for up to five

consecutive days at a time. If the beneficiary remains in the facility longer

than five days, the extra days are billed at the routine home care rate. The

date of discharge is usually billed at the routine home care rate. The inpatient

respite rate may be billed if the discharge is due to the beneficiary’s death.

Inpatient Respite Care counts toward the annual limit on inpatient care. This

service code is limited to once per day per beneficiary, same or different

provider. Inpatient Respite Care is not allowed on the same day as Routine

Home Care, Continuous Home Care or General Inpatient Care. The provider

should provide and bill the appropriate level of service.

0656

General

Inpatient Care

General Inpatient Care is payment made to the hospice for a beneficiary in

an acute care hospital, inpatient facility, or skilled nursing facility. The

service is billed by the day as follows:

•

The number of days that a beneficiary receives general inpatient care is

billed, beginning with the date of admission.

•

The date of discharge is billed at the appropriate rate. If discharge is

delayed while a beneficiary awaits nursing facility placement, the

general inpatient rate can be billed for up to three days. Bill any

subsequent days as if the beneficiary is in a nursing facility; that is, the

routine home care rate plus the appropriate long-term-care rate to cover

room and board. If a beneficiary is discharged as deceased, bill the

general inpatient rate for the date of discharge.

If the beneficiary is hospitalized for a condition not related to the terminal

illness, the hospital bills Medicaid for the beneficiary’s inpatient care.

Additionally, the hospice bills the routine home care rate during the inpatient

stay.

General Inpatient Care counts toward the annual limit on inpatient care. This

service code is limited to once per day per beneficiary, same or different

provider. General Inpatient Care is not allowed on the same day Continuous

Home Care, Inpatient Respite Care or General Inpatient Care: The provider

should provide and bill the appropriate level of service.

0235

Incremental

Nursing Charge

Rate-Hospice-

Service Intensity

Add-On (SIA)

The SIA payment is in addition to the per diem for Routine Home Care

(RHC) rate when all the following criteria are met:

•

The day is an RHC level of care day;

•

The day occurs during the last 7 (seven) days of the beneficiary’s

life;

•

The beneficiary is discharged as expired; and

•

Direct patient care is furnished by a registered nurse (RN) or social

worker (SW) that 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. When end-of-life continuous home care is rendered by the appropriate level of medical

staff (RN- G0299 or SW- G0155) with code RC0235 the claim will process

for authorized provider services.

Note: If G-code is incorrect or missing, the claim will be denied with a

message that indicates the staff level of care is not authorized to provide

care. SIA payment will only apply to visits that occur prior to death. Visit

reported with the PM modifier will not receive an SIA payment. Per CMS

policy, if the social worker provided comfort and grief counseling to the

beneficiary’s family, the social worker time would be reported with the PM

modifier.

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, aides,

social workers, and therapists who are employed by the hospice. This

requirement is applicable for all levels of care (except for GIP provided in a

hospice inpatient facility).

0658

Hospice Nursing

Facility Room and

Board

(Intermediate

Level of Care)

Refer to “Hospice Nursing Facility Room and Board,” below. Revenue code

0658 is used to bill this service if the beneficiary has been approved for

nursing facility care at the intermediate level.

0659

Hospice Nursing

Facility Room and

Board

(Skilled

Level of Care)

Refer to “Hospice Nursing Facility Room and Board,” below. Revenue code

0659 is used to bill this service if the beneficiary has been approved for

nursing facility care at the skilled level or the approval was granted after

May 31, 2004

Hospice Nursing Facility Room and Board

Hospice Nursing Facility Room and Board is the charge billed by the hospice provider for a

beneficiary residing in a nursing facility or ICF/IID. It is billed in addition to routine home care or

continuous home care, as applicable.

Medicaid reimbursement to the hospice is based on 95 percent of the per diem for the individual

nursing facility. The amount is reduced by the amount of the PML when applicable. The hospice

provider reimburses the nursing facility at the negotiated rate determined by the contractual

agreement.

To bill for nursing facility room and board, enter the National Provider Identifier (NPI) number for

the nursing facility where the beneficiary resides in the Service Facility Provider field.

The Attending Provider should be placed in the Attending Provider field. The NPI number entered,

and the revenue code used correspond to the current level of care for the beneficiary, as

determined by the FL-2 approval. Use RC 658 for intermediate level of care and RC 659 for

skilled level of care.

Type of Bill

081X Hospice—Non–hospital based

082XHospice—Hospital based

Note: The fourth digit in the Bill Type is the Frequency Code 0–5. Refer to the Medicare Claims

Processing Manual Chapter 11 - Processing Hospice Claims for the description of applicable code.

Value Code

Hospices billing routine home care, continuous home care, inpatient respite care, or general

inpatient care (Revenue Codes 651, 652, 655, or 656) are required to enter the following

information on the UB-04 form or 837I transaction:

a. A value code of 61 or G8, as applicable, in the Value Code field.

b. the ZIP code for the location where the service was rendered in the Facility Location field.

c. the applicable Core-Based Statistical Area (CBSA) for the location where the care was

provided (such as the beneficiary’s residence, nursing home, assisted living facility, hospital

unit) in the Value Code Amount field.

Unlisted Procedure or Service

CPT: The provider(s) shall refer to and comply with the Instructions for Use of the CPT

Codebook, Unlisted Procedure or Service, and Special Report as documented in the current CPT in

effect at the time of service.

HCPCS: The provider(s) shall refer to and comply with the Instructions for Use of HCPCS

National Level II codes, Unlisted Procedure or Service and Special Report as documented in the

current HCPCS edition in effect at the time of service.