Wyo. Medicaid Institutional Provider Manual § 16.1.3.1

Routine Home Care Payments

Revenue code: 0651

Procedure code: G0493, G0494, G0162

• Billing Example 1:

o Coverage from and to date span (header): 11/01/2022 – 11/30/2022

o Member reaches 61 days on 11/16/2022

61 days and beyond G0493 (RN) or G0494 (LPN)

o Submit one (1) claim with two (2) lines and appropriate service dates on each line

• Dates of service on the lines must be different and accurate

o Submitted charges need to be the Providers usual and customary charges

Line

Revenue

Code

Procedure

Code Dates of Service Units

Submitted Charges

(Usual and Customary)

Approved

Amount

Line 1 0651 Do not

enter a

procedure

code

11/01/2022 –

11/15/2022

15 $3,200.00 $2,828.10

Line 2 0651 G0493 11/16/2022 –

11/30/2022

15 $1,700.00 $2,235.15

• Billing Example 2:

o Coverage from and to date span (header): 11/1/2022 – 11/25/2022

o Member reaches 61 days on 11/16/2022

• 61 days and beyond G0493 (RN) or G0494 (LPN)

o Date of death on file for Member is 11/25/2022

• Patient Status: Expired

o Service Intensity Add-On (SIA) services for the last seven (7) days of a Member’s life: G0162

o For this example, the Provider used the max units each day – seven (7) days x 16 units = 112

total units

o Submit one (1) claim with three (3) lines and appropriate service dates on each line

• Dates of service on the lines must be different and accurate

• Submitted charges need to be the Providers usual and customary charges

Line

Revenue

Code

Procedure

Code Dates of Service Units

Submitted Charges

(Usual and Customary)

Approved

Amount

Line

1

0651 Do not

enter a

procedure

code

11/01/2022 -

11/15/2022

15 $3,200.00 $2,828.10

Line

2

0651 G0494 11/16/2022 -

11/25/2022

10 $1,135.00 $1,490.10

Line

3

0651 G0162 11/19/2022 -

11/25/2022

112 $2,176.96 $1,576.96

• Billing Example 3:

o Coverage from and to date span (header): 11/1/2022 – 11/25/2022

Date of death on file for Member is 11/25/2022

• Patient Status: Expired

Service Intensity Add-On (SIA) services for the last seven (7) days of a Member’s life: G0162

• For this example, the Provider provided three (3) hours of SIA each day - seven (7) days

x 12 units = 84 total units

• Submit one (1) claim with two (2) lines and appropriate service dates on each line

o Dates of service on the lines must be different and accurate

o Submitted charges need to be the Providers usual and customary charges

Line

Revenue

Code

Procedure

Code Dates of Service Units

Submitted Charges

(Usual and Customary)

Approved

Amount

Line 1 0651 Do not

enter a

procedure

code

11/01/2022 –

11/25/2022

25 $5,333.33 $4,713.50

Line 2 0651 G0162 11/19/2022 –

11/25/2022

84 $1,632.72 $1,182.72