CMS released Change Request (CR) 9201 which corresponds to the payment changes that are part of Medicare’s FY 2016 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Requirements (the final rule). The CR is dated August 14, 2015, but was not posted until August 20, 2015. The CR updates the Medicare Claims Processing Manual, Chapter 10 effective January 1, 2016.
The CR implements service intensity add-on (SIA) payments for hospice social worker and nursing visits provided during the last 7 days of life when provided during routine home care. In addition, this instruction will implement two routine home care rates, paying a higher rate in the first 60 days of a hospice election and a lower rate for days 61 and later.
For the SIA payments, CMS will obtain new codes to distinguish between RN services and LPN services since the existing codes do not make this distinction. CMS expects to obtain these new codes as soon as January 1, 2016.
Hospices and key stakeholders have been wondering what changes they will need to make on claims due to the new payment structure for the routine home care (RHC) level of care. CMS indicated in the final rule that it did not anticipate changes to hospice billing instructions. However, hospices will need to include the visit information necessary for the SIA payments on their claims. For eligible stays, the SIA payment will be calculated by the number of hours (in 15 minute increments) of service provided by an RN or social worker during last 7 days of life for a minimum of 15 minutes and up to 4 hours total per day. The claims processing system will determine the SIA payment eligibility of the 7 days preceding death. Hospices will not need to separate RHC line items by the RHC ‘high’ rate or ‘low’ rate. CMS systems will perform these calculations.
As CMS stated in the final rule, there will often be cases where the RHC rate changes during a period RHC that is shown on a single line item on a claim (for example, an RHC line shows 20 days of care and the high RHC rate ends after day 10). The line item should not be split in this case. Existing instructions require that level of care revenue code lines should only be repeated if the site of service changes. A claim submitted with consecutive RHC lines reporting the same site of service HCPCS code will be returned to the provider. Medicare systems will combine the high and low RHC rates for the applicable days in the total payment for the RHC line item. No changes to the electronic remittance advice are planned as a result of this rule. Instructions in CR 9201 are consistent with this direction from CMS.
Hospices have asked whether the sequential billing requirement for hospice will change and CMS indicated in the final rule that while the sequential billing requirement is not being eliminated at this time, CMS will consider whether the elimination of that requirement may be appropriate in the future. (NAHC Report)