Wis. ForwardHealth Online Handbook, Hospice, Topic #1155

Routine care is hospice care that is needed on a regular, part-time basis and is provided in the member's place of residence (for

example, home or nursing facility).

Routine care may be reimbursed for each day that the member is on hospice and at home or permanently residing in a nursing

facility. Wisconsin Medicaid will reimburse a hospice for routine care if less than eight hours of care is provided in a day.

Routine Care Rate Structure

ForwardHealth uses a two-tiered reimbursement rate structure for hospice routine care services based on the count of a member's

hospice days. ForwardHealth reimburses a higher reimbursement rate for a member's first 60 days of hospice care and a lower

reimbursement rate for days 61 and after.

Calculating the Count of Hospice Days

ForwardHealth tracks the count of a member's hospice days and reimburses at the appropriate tiered rate. Hospice providers are

not responsible for keeping track of the count of a member's hospice days.

The count of a member's hospice days includes each calendar day within a member's hospice election period, regardless of the

level of hospice care and whether or not those days are reimbursable by ForwardHealth. A member's hospice election period

begins on the first DOS (date of service) for which hospice care can be reimbursed by ForwardHealth and ends with the

member's decision to discontinue election of hospice care, with the member's hospice-initiated discharge from hospice care, or

with the member's death.

Each calendar day with a member's hospice election period constitutes one DOS and will be counted as one day in calculating the

count of hospice days. The count of hospice days includes hospice days that occurred prior to January 1, 2016; however, the

tiered reimbursement rates do not apply retroactively to DOS prior to January 1, 2016.

The count of hospice days will not reset if the member transfers between hospices within an election period. The transfer day is

counted once in the count of hospice days.

The count of hospice days will not reset between hospice election periods that are fewer than 60 days apart; however, the count

of hospice days will not include days between hospice election periods.

Service Intensity Add-On Payment

ForwardHealth reimburses an SIA (service intensity add-on) payment for routine care services provided by a social worker or an

RN (registered nurse) during the last seven days of a member's life. The SIA payment is in addition to the hospice routine care

reimbursement.

Providers are required to submit claims for SIA payments as follows:

• Services provided by social workers must include HCPCS (Healthcare Common Procedure Coding System) procedure

code G0155 (Services of clinical social worker in home health or hospice settings, each 15 minutes) with revenue code

0562 (Note: Social work telephone calls [revenue code 0569] are not covered under the SIA payment.)

• Services provided by RNs must include HCPCS procedure code G0299 (Direct skilled nursing services of a registered

nurse [RN] in the home health or hospice setting, each 15 minutes) with revenue code 055X

The SIA payment is calculated by multiplying the maximum allowable fee for the appropriate procedure code by the number of

units billed. Each unit represents 15 minutes. A maximum of 16 total units (four hours of service) may be submitted on each DOS.

Note: If the member's last seven days of life begin before January 1, 2016, and end on or after January 1, 2016, the SIA rates

only apply for DOS on and after January 1, 2016.

Additional Claims Submission Instructions for the Service Intensity Add-On Payment

Providers are required to submit occurrence code 55 (Date of Death) with the associated date in MMDDYYYY format and

patient status 20 (Expired) on claims to receive reimbursement for the SIA payment. (Note: Per federal policy, ForwardHealth

does not cover visits for the pronouncement of death under SIA payments.) Providers may refer to the National UB-04 Uniform

Billing Manual prepared by the NUBC (National Uniform Billing Committee) for more information.