The two most significant changes associated with 2016 Hospice Payment Reform are the High vs. Low rates for Routine Home Care (RHC) level of care days and the Service Intensity Add-On (SIA) Payment.

Points Regarding Routine Home Care (RHC) Rates:

  • One rate ($186.84) is paid for care provided from day 1 through day 60 of hospice care
  • A second rate ($146.83) is paid for days 61 and later:
    1. o    ALL DAYS IN HOSPICE COUNT!!  For Example:
      1.     Initial 90 day benefit period is billed as RHC – no other hospice care days have been provided to the patient.
            Day 1-30 billed as RHC (paid at High RHC rate)
            Day 31-40 is billed as GIP
            Day 41-60 is billed as RHC (paid at High RHC rate)
            Day 61-90 is billed as RHC (paid at Low RHC rate)
  • KEY POINT: Even though Days 31-40 are paid at GIP rate once the patient reaches 60 days of hospice care all Routine days will be paid at the Low rate after that time.
  • KEY POINT:  Be sure to understand that the counting of days continues into care provided by a different hospice unless greater than 60 days has passed since the patient revoked or was discharged from the previous hospice election.

Points Regarding Service Intensity Add-On (SIA):

  • CMS has allowed for a Service Intensity Add-on (SIA) that would be added to RHC payment for Registered Nurse (RN) and social work visits provided during the last 7 days of life.
  • The day is billed as a RHC level of care day;
  • The day occurs during the last 7 days of life (and the beneficiary is discharged dead);
  • Direct patient care is provided by a RN or a social worker that day (in person – social worker phone calls are not counted). Minimum 15 minutes/1 unit to a maximum of 4 hours/16 units
  • The SIA payment amount is equal to the Continuous Home Care Rate for that hospice and is paid based on the 15-minute increments/units reported on the claims.
  • KEY POINT:  This does not apply to Post Mortem visit time. 
  • KEY POINT:  Must utilize the new G codes for nursing effective 01/01/16 – G0299 for Registered Nurse (RN) and G0300 for Licensed Practical/Vocational Nurse LPN/LVN

Word or Caution:  Medicare MACs have not gotten all this completely correct in the claims processing centers.  Make sure to double check any discrepancies between your system and the payment amount.