Current through Register Vol. 35, No. 18, September 24, 2024
Hospice providers must submit claims for reimbursement on the
UB-92 claim form or its successor. Election documentation must be submitted
with the initial claim. See 8.302.2 NMAC, Billing for Medicaid
Services. Once enrolled, providers receive instructions on
documentation, billing and claims processing. Medicaid reimbursement for
hospice care is made at one of four prospective daily rates, depending on the
level of care furnished.
The only retroactive adjustment to reimbursement is the
year-end application of the limitation on inpatient care payment. Physician
services are reimbursed separately from the hospice daily rate.
A. Payment for hospice care:
(1) Payment rates for hospice care services
are determined by the centers for medicare and medicaid services (CMS), with
local adjustments for wage differences within each category. Reimbursement for
hospice services is based on one of four all-inclusive daily rate categories.
The daily rate for each category includes all services necessary for palliative
care, such as the purchase of needed medications, durable medical equipment,
and medical supplies. The following are basic categories of hospice care:
(a) "routine home care day" defined as a day
on which the recipient receives hospice care at home that is not defined as
continuous care;
(b) "continuous
home care day" defined as a day on which the recipient is not in an inpatient
facility and receives nursing services for eight consecutive hours in a 24 hour
period; this care is furnished only during brief periods of crisis to maintain
the recipient at home; home health aide or homemaker services can also be
furnished on a continuous basis, but these services are considered routine
care;
(c) "inpatient respite care
day" defined as a day on which a recipient receives care in approved facilities
on a short-term basis to provider respite for the recipient's family or primary
caregiver; and
(d) "general
inpatient care day" defined as a day on which a recipient receives care in
inpatient facilities for pain control or acute or chronic symptom management
that cannot be managed in other settings.
(2) Reimbursement is made to a hospice for
each day on which recipients are eligible for hospice care. Reimbursement is
based on the appropriate payment amount for each day, regardless of the
category of services furnished on any given day.
(3) Reimbursement for a continuous home care
day varies, depending on the number of hours of continuous nursing services
furnished. The continuous home care rate is divided by 24 to yield an hourly
rate. The number of hours of care furnished during the continuous home care day
is multiplied by the hourly rate to yield the continuous home care payment for
that day. Medicaid reimbursement for continuous home care is limited to a
maximum of 72 consecutive hours of service.
(4) The inpatient reimbursement rate for
approved facility for short-term inpatient care depends on the category of care
furnished, either inpatient respite or general inpatient.
(a) Reimbursement for inpatient respite care
is limited to a maximum of five consecutive days at a time. Medicaid pays for
the sixth and any subsequent day of respite care at the routine home care
rate.
(b) Medicaid pays the
inpatient rate for the admission date and all subsequent inpatient days. For
the discharge day, the applicable home care rate is reimbursed. Reimbursement
for the discharge day when the recipient is discharged deceased is made at the
inpatient rate.
(c) Reimbursement
for all inpatient care is subject to a limitation that total inpatient care
days for medicaid recipients cannot exceed twenty percent of the total days for
which these recipients elected hospice care. The calculation and any necessary
retroactive adjustment of overall payments per provider is completed during the
cap period. See 42 CFR
418.302 (f).
B. Reimbursement for
physician services:
(1) Medicaid covers the
following services performed by hospice physicians as part of the general
reimbursement rate for hospice care services:
(a) general supervisory services of the
medical director; and
(b)
participation in establishing, reviewing and updating plans of care,
supervision of care and services, and establishment of governing policies by
the physician member of the interdisciplinary group.
(2) For direct patient care services
furnished by a hospice employee or a physician working under arrangement with
the hospice, not listed above, medicaid reimburses the hospice for each
procedure at the lesser of the medicaid fee schedule or the amount
billed.
(3) Medicaid does not pay
for physician services furnished on a volunteer basis.
(4) Medicaid does not cover physician
services furnished by the recipient's attending physician as a hospice service,
if he or she is not an employee of the hospice or providing services under
arrangements with the hospice. Only the attending physician can bill for these
services.