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

Providers shall bill their usual and customary charges.

For a schedule of rates, refer to: https://medicaid.ncdhhs.gov/ .

Payment rates for hospice services are equivalent to Medicare hospice rates, and Medicare

methodology is followed. For Medicaid, only, the hospice reimbursement rate for nursing facility

room and board is 95 percent of the nursing facility rate.

The reimbursement rate for routine home care, continuous home care, inpatient respite care, and

general inpatient care (Revenue Codes 651, 652, 655, or 656) is dependent on the beneficiary’s

location by Core-Based Statistical Areas (CBSA) on the date of service. Level of Care Categories.

Each day of the beneficiary’s hospice coverage is classified at one (1) of four (4) levels of care.

The Medicaid reimbursement for the service is made at a per diem rate based on the level of care

and the location at which the service is furnished to the beneficiary.

Payment amounts are determined within each of the following categories.

Routine Home Care

Hospice shall comply with 42 CFR §418.302 Payment procedures for hospice care.

Routine Home Care (RHC) is the basic level of care provided to support a hospice beneficiary. It

is provided in a primary private residence, a hospice residential care facility, a nursing facility, or

an adult care home. When the care is provided in a nursing facility or adult care home, the hospice

and the facility shall have a written contractual agreement for the services to be provided in the

facility.

Two Tier Rate

The FY2016 Medicare Hospice Payment Reform,42 CFR418, replaces the single RHC per diem

rate with two different RHC payment rates:

a. A higher payment rate for the first 60 days (Tier 1) of hospice care; and

b. A reduced payment rate for 61days (Tier 2) and over of hospice care

A 60-day gap in hospice services is required to reset the counter that determines if a beneficiary is

qualified for the Tier 1 (day one) through sixty (60) days) payment rate when remitted back in to

Hospice.

Service Intensity Add-On (SIA)

The FY 2016 Medicare Hospice Payment Reform, 42 CFR 418, also implemented a Service

Intensity Add-On (SIA) payment. 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;

b. The service 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 social worker (SW) on the

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 registered nurse (RN) or social worker (SW) 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). Although LPN are

not able to provide services which received SIA payment, G-code has been added for the skill

level.

HCPCS

Code(s)

Description

G0299

Direct skilled nursing services of a registered nurse (RN) in the home

health or hospice setting, each 15-minute increment up to 4 hours per

day.

G0300

Direct skilled nursing of a licensed practical nurse (LPN) in the home

health or hospice setting, each 15-minute increment up to 4 hours per

day.

G0155

Services of a clinical social worker (SW) in Home Health or Hospice

Settings, each 15-minute increment up to 4 hours per day.

Note: NCTracks no longer allows Hospice providers to bill status code 20 to denote the death of

Hospice beneficiary. Guidance from Chapter 11 Medicare Claim Processing Manual specifically

states that status of 20 is no longer used on Hospice Claims and these claims using status of 20

will deny.

Therefore, valid discharge codes denoting death of the patient for hospice claims were created.

Discharge

Code(s)

Continuous

Home

Care

Description

40

Expired at Home

41

Expired at Medical Facility

42

Expired Place Unknown

Continuous Home

Care is provided during a medical crisis, as needed to keep the beneficiary at home and when the

hospice IDG determines that continuous care, primarily nursing care, is needed to achieve

palliation or management of acute medical symptoms. The care must be needed for a minimum of

eight (8) hours of the calendar day. The hours may be split into two or more periods during the

day. An RN or LPN shall provide nursing services for at least half of the hours of care in a day.

Homemaker and home health aide services may be used to supplement the nursing care for the

remaining hours. It can be provided in the private residence, hospice residential care facility, long

term care facility, adult care home, or nursing facility.

Inpatient Respite Care

Inpatient Respite care is short-term inpatient care provided to the beneficiary only when necessary

to relieve the family members or other persons caring for the individual at home. Respite care may

only be provided in a Medicare participating hospital or hospice inpatient facility, or a Medicare or

Medicaid participating nursing facility. Respite care may be provided only on an occasional basis

and may not be reimbursed for more than five consecutive days at a time. Respite care provided

for more than five consecutive days at a time must be billed as routine home care for day 6 and

beyond, and the patient may be liable for room and board charges for day six and beyond. See

§40.1.5 for additional information. The hospital or nursing facility shall meet the special hospice

standards for staffing and patient care areas as specified in 10A NCAC 13K and 42 CFR 418. For

a detailed explanation on determining annual limitations as it relates to inpatient care, refer to 42

CFR 418.

General Inpatient Care

General Inpatient Care is for the management of symptoms or to perform procedures for pain

control that cannot be performed in other settings. The care is provided in a hospice inpatient

facility, a hospital, or a nursing facility under arrangement with the hospice provider. The hospital

or nursing facility shall follow the special hospice standards for staffing and patient care areas as

specified in 10A NCAC 13K and 42 CFR 418.108. For a detailed explanation on determining

annual limitations on payments to inpatient care, refer to 42 CFR 418.

Bereavement Counseling

Bereavement counseling consists of counseling services provided to the beneficiary’s family

before and after the individual’s death. Bereavement counseling is a required hospice service,

provided for a period up to one year following the beneficiary’s’ death. It is not separately

reimbursable. Bereavement specifics are found in Pub. 100-07, State Operations Manual,

Appendix M, 42 CFR 418.64(d)(1), L596

Special Modalities

Drugs and biologicals pertaining to the terminal diagnosis are reimbursed to the hospice as part of

the hospice per diem. Medicaid shall directly reimburse the pharmacy for drugs used to treat

illnesses or conditions not related to the terminal illness.

A hospice may use chemotherapy, radiation therapy, and other modalities for palliative purposes if

it determines that these services are needed. This determination is based on the patient’s condition

and the individual hospice’s care-giving philosophy. No additional Medicaid payment may be

made regardless of the cost of the services.