Wyo. Medicaid Institutional Provider Manual § 16.1.3

Hospice care services will be available to Medicaid eligible Members of any age and may be provided in

a home setting, nursing facility, or freestanding hospice facility when the Member meets the following

criteria:

• A Member is certified by a physician as being terminally ill – meaning that a physician has

certified that if the illness runs its normal course, the Member’s life expectancy is six (6) months

or less.

• The Member or designee has completed a Hospice Benefit Election Form (see Section 16.1.1.1

Hospice Benefit Election Form), which must be submitted to Medicaid along with the physician

certification of terminal illness.

• An individual must be determined financially eligible through the Department of Health Long

Term Care Unit before receiving hospice services.

The hospice Provider is responsible for medical care and services related to the terminal illness which

are provided to the Member who has elected palliative care. The hospice Provider can bill for:

Revenue Code Procedure Code Description

0651 N/A Routine home care (day 1 through day 60)

0651 G0493 61 days and beyond – skilled services of a registered nurse (RN) for the

observation and assessment of the patient’s condition

0651 G0494 61 days and beyond – skilled services of a licensed practical nurse (LPN)

for the observation and assessment of the patient’s condition

0651 G0162 Service Intensity Add-On (SIA) services for the last 7 days of a Member's

life when provided by a Registered Nurse or Social Worker in the last

seven (7) days of the Member’s life.

• 16 max daily units (4 hours/day, 15 minutes = 1 unit)

0652 N/A Continuous home care

0655 N/A Inpatient respite care

0656 N/A General inpatient care

0658 N/A Nursing facility room and board

0659 N/A Inpatient hospice room and board

Services provided in an inpatient setting must conform to the written plan of care. General inpatient

hospital care may be required for procedures necessary for pain control and acute or chronic symptom

management.

Hospice Member lifetime 60-day limit:

• A Member’s hospice days will be calculated over a lifetime, meaning they will never reset.

• Once a Member exceeds 60 days the Provider must bill with the procedure code.

• It is the Provider’s responsibility to track the number of days for each Member.

• Error Code 7063: Hospice Limit: Member exceeded 60 days or received 60 or less of routine

home care & procedure code G0493 or G0494 was not billed or was billed with rev code 0651.

SIA services:

For claims to process to payment,

• Medicaid must have the Member’s date of death on file and the dates of service are within the

prior seven (7) days. Claims will be held as “in process” for 30 days pending the date of death

and will deny after 30 days if no date of death is received.

• The SIA service is only billable in conjunction with routine home care (revenue code 0651).

Hospice Members under the age of 21 (Pediatric Hospice Election) are

allowed concurrent care and reimbursement of medical care through

the usual and customary billing procedures. All other Provider and

facility claims will be processed without the requirement of the

Hospice Exemption Form (services unrelated to the Member’s

terminal illness.

Level of Care Bill Type Revenue Code

Routine Home Care 82X 0651

The hospice Provider is to bill the routine home care rate for each day the Member is under their care and

another level of care is not reimbursed. The rate is a per diem rate. See billing information below table.

Continuous Home Care 82X 0652

Continuous home care is to be provided by the hospice only during a period of crisis. Bill the continuous home

care rate when continuous home care is provided. Reimbursement is for every hour or part of an hour of care

furnished up to a maximum of 24 hours a day. A minimum of at least eight (8) hours a day must be provided.

One (1) unit equals one (1) hour of service. The rate is an hourly rate.

Inpatient Respite Care 81X 0655

Respite care is reimbursed to an approved inpatient facility for a maximum of five (5) consecutive days at a time

including the date of admission but not counting the date of discharge. The rate is a per diem rate.

Level of Care Bill Type Revenue Code

General Inpatient Care 81X 0656

The hospice is to bill the general inpatient rate when general inpatient care is provided. If the Member is

discharged from general inpatient care as deceased, the general inpatient rate is billed for that day. If they are

discharged to home, the appropriate home care rate is billed on a separate claim form. The rate is a per diem

rate.

Nursing Facility Hospice Room and Board 81X 0658

The hospice Provider is to bill the nursing facility room and board component when the individual is a nursing

facility resident. The hospice Provider is responsible for paying the nursing facility. Use the Provider number

assigned to the hospice Provider for nursing facility resident's room and board. Revenue codes 0652, 0656, and

0659 cannot be billed with revenue code 0658. The rate is a per diem rate.

NOTE: For this rate to be assigned, the hospice Provider needs to complete and submit the Hospice NH Room &

Board Request Form (see Section 16.1.1.2 Hospice NH Room & Board Request Form) when the Member elects

hospice services (see Section 16.1.1 Electing Hospice Services).

Inpatient Hospice Room and Board 81X 0659

The hospice Provider is to bill the inpatient hospice room and board rate for each day a Member is in the

hospice facility receiving care or in the inpatient hospice facility receiving respite care. Revenue codes 0652,

0656, and 0658 cannot be billed with revenue code 0659. The rate is a per diem rate. There is no Member

copay.