Provider Notice issued 01/29/16

New Two-Tier Routine Home Care (RHC) Rates and End of Life Service Intensity

To: Participating Hospice Providers
Date: January 29, 2016
Re: New Two-Tier Routine Home Care (RHC) Rates and End of Life Service Intensity

The Centers for Medicare and Medicaid Services (CMS), per a final rule in the August 6, 2015 Federal Register, identified changes to the Medicare hospice program related to payment for routine home care (RHC) and payment for a new service intensity add-on (SIA) payment. By letter to CMS associate regional administrators on September 1, 2015, CMS verified to states that these payment changes also affect Medicaid hospice payments, as Medicaid hospice rates are calculated based on the annual hospice rates established under Medicare.

Routine Home Care Two-Tier Payment System

Effective with dates of service on and after January 1, 2016, and for patients who have hospice elections on file with a begin date on or after January 1, 2016, the Department will reimburse RHC on a two-tier system. Days 1 through 60 will be paid based upon a higher rate, while days 61 and beyond will be paid at a lower rate. The eligibility for these rates follows the patient eligibility and not the hospice provider billed on the claims. For a hospice patient who has been discharged and readmitted to hospice within 60 days of that discharge, the prior hospice days will continue to follow the patient in the determination of the appropriate rate. For a hospice patient who has been discharged from hospice care for more than 60 days, a new election to hospice will initiate a reset of the patient’s 60-day window and the patient will requalify for the higher rate.

The following table reflects the rates effective January 1, 2016 through September 30, 2016:

The high/low rates will be adjusted by the CBSA Wage Index multiplier.

Example 1 (high rate):  CBSA Code 16020 has an associated Wage Index of 0.9094. Wage Index 0.9094 multiplied by the Wage Component of $128.54 equals a base rate of $116.89. The Base Rate of $116.89 plus the Non-weighted Amount of $58.54 equals the Daily Rate of $175.43.

Example 2 (low rate):  CBSA Code 16020 has an associated Wage Index of 0.9094. Wage Index 0.9094 multiplied by the Wage Component of $101.02 equals a Base Rate of $91.87.  The Base Rate of $91.87 plus the Non-weighted Amount of $46.00 equals the Daily Rate of $137.87.

End of Life Service Intensity Add-on Payment

Effective with service From Dates on and after January 1, 2016, an SIA payment may be billed for visits by a social worker or registered nurse (personnel defined in 42 CFR Part 418.114), when provided during RHC during the last seven days of life. The SIA payment is in addition to the RHC payment. The SIA hourly rate is derived from the hospice Continuous Home Care hourly rate, and is payable in 15-minute increments (one unit = 15 minutes).

The eligible SIA payment revenue lines may only encompass at a maximum the last seven days of life. The maximum number of hours allowed per day is four hours (16 units) for either the social worker services or registered nurse services or a combination of the two services. If more than 16 units per day are billed for either 055X or 056X, the claim will reject. If the combination of 055X & 056X exceeds 16 units per day, the additional units will be ignored, as long as neither 055X nor 056X exceed the maximum individually. If the number of SIA days billed is less than seven, the provider may only bill the maximum units allowed per day. To receive the SIA, the claim must contain RHC Revenue Code 0651 and the patient Discharge Status must indicate “Death” as identified in the UB-04 Data Specifications Manual.

Billing for Registered Nurse Services – Services provided by a registered nurse must be billed with HCPCS code G0299 and Revenue Code 055X.

Billing for Social Work Services – Services provided by a social worker must be billed with HCPCS code G0155 and Revenue Code 056X. This service may not be provided by a social worker via telephone.

The following table reflects the rate effective January 1, 2016 through September 30, 2016:

Example: CBSA Code 16020 has an associated Wage Index of 0.9094. Wage Index 0.9094 multiplied by the Wage Component of $27.06 equals a base rate of $24.61. The Base Rate of $24.61 plus the Non-weighted Amount of $12.32 equals the Hourly Rate of $36.93. The Hourly Rate divided by four equals $9.23 per 15-minute unit.

New Error Codes

The Department has developed two new error messages in conjunction with these hospice payment changes:

K16 – Service Intensity Add-on Billing Invalid. This edit will generate if:

• Revenue Code 055X or 056X is billed and the Service Through Date is earlier than January 1, 2016; or
• The claim contains Revenue Codes 055X or 056X but does not contain Revenue Code 0651; or
• 055X or 056X is billed but the Patient Status is not equal to 20, 40, or 42; or
• 055X or 056X is billed in units exceeding the derived maximum allowed; or
• 055X is billed and the claim does not have corresponding G0299 HCPCS code, or 056X is billed and the claim does not have corresponding G0155 HCPCS code.

K17 – Routine Home Care Days Paid at High Rate. This is not a rejection message, but is informational if the claim contains Revenue Code 0651 and payable days are paid at the higher rate (first 60 days of care). The number of days paid at the higher rate will appear on the paper Remittance Advice for tracking purposes.

Note: The billing instructions in this notice apply to patients enrolled in traditional fee-for-service, Accountable Care Entities (ACEs), and Care Coordination Entities (CCEs), and do not apply to patients enrolled in Managed Care Organizations (MCOs) and Managed Care Community Networks (MCCNs).

It is imperative that providers check HFS electronic eligibility systems regularly to determine beneficiaries’ enrollment in a plan. The Recipient Eligibility Verification (REV) System, the Automated Voice Response System (AVRS) at 1-800-842-1461, and the Medical Electronic Data Interchange (MEDI) system will identify any care coordination plan in which the beneficiary is enrolled. Plan contact information for questions related to coverage and billing requirements, as well as information regarding the way each plan is displayed in the Department’s electronic eligibility systems may be located in the March 9, 2015 informational notice titled, Care Coordination Health Plan Identification and Billing Procedures Depending on Health Plan Enrollment (pdf).

Any questions regarding this notice may be directed to a billing consultant in the Bureau of Hospital and Provider Services at 1-877-782-5565.

Felicia F. Norwood
Director