S.D. Medicaid Billing and Policy Manual, Hospice Services, Covered Services and Limits

General Coverage Principles

Providers should refer to the General Coverage Principles manual for basic coverage requirements all

services must meet. These coverage requirements include:

• The provider must be properly enrolled;

• Services must be medically necessary;

• The recipient must be eligible; and

• If applicable, the service must be prior authorized.

The manual also includes non-discrimination requirements providers must abide by.

Notification to the Department

A statement of election, revocation, death or discharge must be sent to the Department of Social

Services, Division of Economic Assistance within five working days after the hospice provider obtains

the signed statement from the recipient. Payment for hospice services will not be made until the

appropriate documentation has been received by the Department.

A statement of election, revocation, death or discharge form is available on South Dakota Medicaid’s

website. A hospice provider may design and print a statement of certification, election, and revocation

of election form to use instead of the form provided by South Dakota Medicaid. If a hospice provider

chooses to create a form, it must contain the same information as the form provided by South Dakota

Medicaid. For recipients dually eligible for Medicare and Medicaid, the statements used for Medicare

may be used if appropriate references to Medicaid are included. For example, an election form should

include a statement acknowledging the recipient waives Medicaid as well as Medicare benefits.

General Hospice Coverage Requirements

Hospice provided to dually eligible recipients must be provided first in accordance with Medicare

policies, rules, regulations, and guidelines and second by the policies set forth the State Medicaid

Manual and the coverage criteria in this manual.

To be covered hospice services must meet the following requirements:

• The services must be reasonable and necessary for the palliation and management of the

terminal illness as well as related conditions;

• The recipient must elect hospice care in accordance with the requirements in this manual;

• A plan of care must be established and periodically reviewed by the attending physician, the

medical director, and the interdisciplinary team of the hospice program;

• The plan of care must be established before hospice care is provided;

• The services provided must be consistent with the plan of care;

A certification that the recipient is terminally ill must be completed in accordance with the requirements

of this manual.

Plan of Care

An interdisciplinary team, which may consists of a include a nurse, physician, medical social worker or

counselor with one of these individuals being a nurse or physician or other licensed practitioner, must

assess a recipient’s needs and develop a written plan of care before hospice services are provided.

The other members of the interdisciplinary team must review and provide input to the plan of care

within two working days following the day of assessment. For the assessment day to be a covered day

of hospice service, the plan of care must be established on the same day as the assessment. Services

provided by the hospice must be consistent with the plan of care and must be reasonable and

necessary for palliation or management of the terminal illness and related conditions.

HCBS Waiver Services

Recipients may receive both HCBS waiver services and hospice services if the HCBS waiver services

were in place prior to the hospice services being elected and are unrelated to the terminal illness that

resulted in the election of hospice care. It may be appropriate for HCBS waiver services to be approved

after a recipient has elected hospice services if the HCBS services are unrelated to the terminal illness

that resulted in the election of hospice care. HCBS waiver services may not be utilized as a means by

hospice providers to forgo providing core and supplemental services that they are required to provide.

Covered Core Services

The hospice must provide core services to the recipient based upon the recipient’s individual needs.

Core services, with the exception of physician services, must be provided directly by hospice

employees on a routine basis. These services must be provided in a manner consistent with acceptable

standards of practice. All services must be performed by appropriately qualified personnel. The

following are considered hospice core services:

• Physician services;

• Nursing services;

• Medical social services and

• Counseling.

Physician Services (Core Service)

A physician must perform physicians' services (as defined in 42 CFR 410.20(b)(1)(1)), except that the

services of the hospice medical director or the physician member of the interdisciplinary team must be

performed by a doctor of medicine or osteopathy. Nurse practitioners may not serve as a medical

director or as the physician member of the interdisciplinary group. The hospice face-to-face encounter

is an administrative requirement related to certifying the terminal illness. By itself, it is not billable, as it

is considered administrative. However, if a hospice physician, or a hospice nurse practitioner who is

also the recipient’s attending physician, provides reasonable and necessary non-administrative

recipient care during the face-to-face visit, that portion of the visit would be billable.

Attending Physician and Nurse Practitioner Services (Core Services)

The attending physician is a doctor of medicine or osteopathy, a nurse practitioner, or a physician

assistant and is identified by the individual, at the time he or she elects to receive hospice care, as

having the most significant role in the determination and delivery of the recipient’s medical care.

The election statement must include the recipient’s choice of attending physician. The information

identifying the attending physician should be recorded on the election statement in enough detail so

that it is clear which physician, NP, or PA was designated as the attending physician. This information

should include, but is not limited to, the attending physician’s full name, office address, NPI number, or

any other detailed information to clearly identify the attending physician. Hospices have the flexibility to

include this information on their election statement in whatever format works best for them, provided the

content requirements in 42 CFR 418.24(b) are met. The language on the election form should include

an acknowledgement by the recipient (or legal representative) that the designated attending physician

was the recipient’s (or legal representative’s) choice.

If a recipient (or legal representative) wants to change his or her designated attending physician, he or

she must follow a procedure similar to that which currently exists for changing the designated hospice.

Specifically, the recipient (or legal representative) must file a signed statement with the hospice that

identifies the new attending physician in enough detail so that it is clear which physician, NP, or PA was

designated as the new attending physician. This information should include, but is not limited to, the

attending physician’s full name, office address, NPI number, or any other detailed information to clearly

identify the attending physician. The statement must include the date the change is to be effective, the

date that the statement is signed, and the recipient’s (or legal representative’s) signature, along with an

acknowledgement that this change in the attending physician is the recipient’s (or legal

representative’s) choice. The effective date of the change in attending physician cannot be earlier than

the date the statement is signed.

Physician services can be provided by nurse practitioners or physician assistant’s only if the:

• Nurse practitioner or physician assistant is the recipient's designated attending physician; and

• Services are medically reasonable and necessary; and

• Services are performed by a physician in the absence of the nurse practitioner or physician

assistant; and

• Services are not related to the certification of terminal illness.

Services that are duplicative of what the hospice nurse would provide are not separately billable for a

nurse practitioner or physicians assistant. Physician assistants cannot perform the face-to-face

encounter.

Nursing Services (Core Service)

Nursing services provided by or under the supervision of a registered nurse. Services must require the

skills of a registered nurse or licensed practical nurse and must be reasonable and necessary for the

palliation and management of the patient’s terminal illness and related conditions. Services provided by

a nurse practitioner who is not the patient’s attending physician, are included under nursing care. In this

scenario, since the services are nursing, payment is encompassed in the hospice per diem rate and

may not be billed separately regardless of whether the services are provided by a nurse practitioner or

a registered nurse.

Medical Social Services (Core Service)

Social services provided by a social worker under the direction of a physician or other licensed

practitioner. Social workers must meet the qualification requirements in 42 CFR 418.114(b)(3). Services

of these professionals which may be covered include, but are not limited to:

• Assessment of the social and emotional factors related to the patient’s illness, need for care,

response to treatment and adjustment to care;

• Assessment of the relationship of the recipient’s medical and nursing requirements to the

recipient’s home situation, financial resources and availability of community resources;

• Appropriate action to obtain available community resources to assist in resolving the recipient’s

problem;

• Counseling services that are required by the recipient;

• Medical social services furnished to the recipient’s family member or caregiver on a short-term

basis when the hospice can demonstrate that a brief intervention (that is, two or three visits) by

a medical social worker is necessary to remove a clear and direct impediment to the effective

palliation and management of the patient’s terminal illness and related conditions. To be

considered “clear and direct,” the behavior or actions of the family member or caregiver must

plainly obstruct, contravene, or prevent the recipient’s medical treatment. Medical social

services to address general problems that do not clearly and directly impede treatment, as well

as long-term social services furnished to family members, such as ongoing substance misuse

counseling, are not covered.

Counseling Services (Core Service)

Counseling services provided to the recipient and family member or other persons caring for the

recipient at the recipient’s home. Counseling, including dietary counseling, may be provided to train the

recipient’s family or caregiver to provide care and help the recipient, family members, and caregivers

adjust to the recipient’s approaching death.

Bereavement counseling is available to the recipient and his or her immediate family to provide

emotional, psychosocial, and spiritual support and services before and after the death of the recipient

and to assist with issues related to grief, loss, and adjustment for up to 1 year after the recipient’s

death. It is not separately reimbursable.

Covered Non-Core Services

In addition to the hospice core services (physician services, nursing services, medical social services,

and counseling), the following services must be provided by the hospice, either directly or under

arrangements, to meet the needs of the recipient and family and are not separately billable.

The hospice may contract for supplemental services provided during periods of peak patient load or for

extraordinary circumstances. All services must be performed by appropriately qualified personnel,

skilled nursing facility (SNF) or nursing facility (NF) that additionally meets the special hospice

standards regarding patient and staffing areas. Services provided in an inpatient setting must conform

to the written plan of care.

Medical Appliances and Supplies (Supplemental Service)

Medical appliances and supplies may be provided, including drugs and biologicals. Drugs which are

used primarily for the relief of pain and symptom control related to the individual’s terminal illness are

covered. This includes both prescription and over-the-counter drugs.

Appliances may include covered durable medical equipment as well as other self-help and personal

comfort items related to the palliation or management of the patient’s terminal illness. Equipment is

provided by the hospice for use in the recipient’s home while the recipient is under hospice care.

Medical supplies include those that are part of the written plan of care and that are for palliation and

management of the terminal illness or related conditions.

Home Health Aide and Homemaker Services (Supplemental Service)

Home health aide (hospice aide) services and homemaker services which include personal care

services and household services, such as changing a bed, light cleaning and laundering, necessary to

maintain a safe and sanitary environment in areas of the home used by the recipient. Aide services

must be provided under the supervision of a registered nurse. Written patient care instructions for a

hospice aide must be prepared by a registered nurse who is responsible for the supervision of a

hospice aide. The hospice aide must meet the Medicare conditions of participation requirements in 42

CFR 418.76.

Therapy Services (Supplemental Service)

Physical therapy, occupational therapy, and speech and language pathology services may be provided

for symptom control or to enable the recipient to maintain activities of daily living and basic functional

skills.

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. Services are considered reimbursed through the

standard Medicaid hospice reimbursement.

Treatment of Terminal Condition

When hospice is elected by a recipient age 21 or older, the recipient is no longer eligible for any

Medicaid services related to the treatment of the terminal condition for which hospice care was elected,

a related condition or the equivalent to hospice care. The recipient is still eligible for treatment of

conditions unrelated to the terminal condition.

Individuals age 20 or younger may receive hospice services and continue to receive other Medicaid

covered services that are not duplicative of hospice care for the terminal condition, a related condition,

or unrelated condition.

Levels of Hospice Care

South Dakota Medicaid covers four levels of hospice care. Services must be provided by a provider that

meets the criteria in the Eligible Providers section of this manual. The level of hospice care that is

covered each day depends on the type and intensity of the services furnished to the recipient on the

date of service. Coverage and reimbursement is limited to one of the levels of hospice care described

below per day.

Routine Home Care Day (Revenue Code 651)

A routine home care day is a day on which an individual who has elected to receive hospice care is at

home and is not receiving continuous care. In addition to a traditional place of residence, for purposes

of routine home care a recipient’s home may be a skilled nursing facility, ICF-IID, swing bed, assisted

living center, residential hospice, community support provider, or inpatient hospice. On any day on

which the recipient is not an inpatient, the hospice provider is reimbursed the routine home care rate,

unless the recipient receives continuous care for a period of at least 8 hours.

Service Intensity Add-On - End of Life (Revenue Code 551 and 561)

Routine home care days that occur in the last 7 days of a recipient’s life are eligible for a service

intensity add-on when direct patient care is provided by one of the following:

• Registered nurse (Revenue Code 551, HCPCS G0299);

• Licensed practical nurse (Revenue Code 551, HCPCS G0300);

• Social worker (Revenue Code 561, HCPCS G0155).

Services must be billed in 15-minute increments and are limited to 16 combined units per day. The

service intensity add-on rate is the same as the continuous home care rate.

Continuous Home Care Day (Revenue Code 652)

A continuous home care day is a day in which the recipient receives nursing services, which may

include hospice aide or homemaker services, on a continuous basis during a period of crisis, for at least

eight hours and as many as 24 hours per day, as necessary to maintain the recipient at home. More

than half the care during the crisis must be nursing care provided by a registered nurse or licensed

practical nurse. Continuous home care is only furnished during brief periods of crisis and only as

necessary to maintain the terminally ill recipient at home. A period of crisis is a period in which the

individual requires continuous care to achieve palliation and management of acute medical symptoms.

In addition to a traditional place of residence, for purposes of continuous home care a recipient’s home

may be a skilled nursing facility, ICF-IID, swing bed, assisted living center, residential hospice,

community support provider, or inpatient hospice.

The 24-hour day begins and ends at midnight. This care need not be continuous, i.e., 4 hours could be

provided in the morning and another 4 hours provided in the evening of that day. The hospice provider

is reimbursed on an hourly basis for every hour of continuous home care furnished up to a maximum of

24 hours a day.

While in the majority of situations, one individual would provide continuous care during any given hour,

there may be circumstances where the recipient’s needs require direct interventions by more than one

covered discipline resulting in an overlapping of hours between the nurse and hospice aide. In these

circumstances, the overlapping hours would be counted separately. The total hours paid cannot exceed

24 hours per day. Documentation of care, modification of the plan of care, and supervision of aides or

homemakers would not qualify as direct care nor would these activities qualify as necessitating the

services of more than one care provider. In addition, while the services provided by other disciplines

such as medical social workers, pastoral counselors, marriage and family therapists or mental health

counselors are an integral part of the care provided to a hospice recipient, these services are not

included in the definition of continuous care and are not counted towards total hours of continuous care.

However, the services of social workers, pastoral counselors, marriage and family therapists or mental

health counselors would be expected during these periods of crisis, if warranted as part of hospice

care, and are included in the provisions of routine hospice care.

When a hospice determines that a recipient meets the requirements for continuous home care,

appropriate documentation must be available to support the requirement that the services provided

were reasonable and necessary and were in compliance with an established plan of care in order to

meet a particular crisis situation. This would include the appropriate documentation of the situation and

the need for continuous care services consistent with the plan of care.

Inpatient Respite Care (Revenue Code 655)

An inpatient respite care day is a day on which the individual who has elected hospice care receives

care in an approved facility on a short-term basis for respite. Respite care is short-term inpatient care

provided to the individual only when necessary to relieve the family members or other persons caring

for the individual. In addition to a traditional place of residence, inpatient respite care is covered for

recipients residing in assisted living centers, residential hospices, or community support providers.

Inpatient respite care may be provided in a hospital, nursing facility, or inpatient hospice that meets the

conditions of participation in 42 CFR 418.108.

Several examples of appropriate respite care for a recipient who does not reside in a facility include

providing a few days for the caregiver to rest at home, to visit family, attend a wedding, or attend a

graduation for a needed break, or providing a few days immediately following a GIP stay if the usual

caregiver has fallen ill.

Coverage for inpatient respite care is limited to 5 consecutive days beginning with the day of admission

but excluding the day of discharge. Any inpatient respite care days in excess of 5 consecutive days

must be billed as routine home care.

Revenue code 655 includes room and board. Revenue code 659 may not be billed in addition to it.

General Inpatient Care Day (Revenue Code 656)

A general inpatient care day is a day on which an individual who has elected hospice care receives

general inpatient care in an inpatient facility for pain control or acute or chronic symptom management

which cannot be managed in other settings. This level of hospice care may only be provided in a skilled

nursing facility, ICF-IID, swing bed, inpatient hospice, or hospital. Inpatient care is provided for a limited

period of time as determined by the physician and interdisciplinary team.

General inpatient care under the hospice benefit is not equivalent to a hospital level of care under the

Medicaid hospital benefit. For example, a brief period of general inpatient care may be needed in some

cases when a patient elects the hospice benefit at the end of a covered hospital stay. If a patient in this

circumstance continues to need pain control or symptom management, which cannot be feasibly

provided in other settings while the patient prepares to receive hospice home care, general inpatient

care is appropriate.

Other examples of appropriate general inpatient care include a patient in need of medication

adjustment, observation, or other stabilizing treatment, such as psycho-social monitoring. It is not

appropriate to bill Medicaid for general inpatient care days for situations where the individual has lost

caregiver support unless the coverage requirements for the general inpatient level of care are otherwise

met. For a hospice to provide and bill for the general inpatient level of care, the patient must require an

intensity of care directed towards pain control and symptom management that cannot be managed in

any other setting.

42 CFR 418.110 specifies the conditions of participation for general inpatient hospice care and should

be reviewed in its entirety. All condition-of-participation requirements must be met whether a hospice

provides general inpatient care in its own inpatient unit or by arrangement with another entity. Unless

the nursing facility is a skilled nursing facility in a hospital setting, most nursing facilities do not meet the

skilled nursing requirement for this level of care. Specifically, the nursing facility must provide 24-hour

registered nurse coverage and the registered nurse at the nursing facility must be capable of providing

the pain management required for this level of hospice care. The presence of a registered nurse on

staff at the nursing facility for 24 hours per day is not sufficient to meet the requirements.

The day of admission to the facility is general inpatient care and the day of discharge is not general

inpatient care, unless the recipient is discharged deceased. Reimbursement for general inpatient care

may not be made to a long-term care facility when that facility is considered the recipient’s home;

however, payment for general inpatient care can be made to another long-term care facility rendering

this level of hospice care.

Revenue code 656 includes room and board. Revenue code 659 may not be billed in addition to it.

Room and Board (Revenue Code 659)

Once a nursing facility resident elects hospice, the recipient is considered a hospice patient and no

longer a nursing facility patient for billing purposes.

For dually enrolled Medicare and Medicaid eligible recipients receiving one of the categories of hospice

care, coverage and reimbursement is limited to the recipient’s room and board. Medicare will pay for

the hospice care at the applicable routine home care rate. Medicaid will reimburse the hospice the

routine home care rate, plus the established room and board rate for patients who are not dually

eligible. Medicaid payment for the room and board is to the hospice provider and the hospice provider

must reimburse the nursing facility for room and board.

Room and board reimbursement does not include the day of discharge or death from hospice. The

hospice will be reimbursed for hospice clinical services provided on the date of death and discharge,

but not for room and board.

Revenue code 659 may not be billed in addition to revenue code 655 or 656 as room and board are

already included in the reimbursement for those revenue codes.