Description
This policy addresses reimbursement for hospice services.
Type of Service
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Definition
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Hospice
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A hospice is defined as an organization that provides medical, social, and psychological services in the home or inpatient facility as palliative treatment for patients with a terminal illness or life expectancy of less than six months.
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Policy
Blue Cross Blue Shield of ND (BCBSND) reimburses free standing and hospital-based hospice services on a uniform fee schedule rate. Reimbursement is based on the lesser of charges or fee schedule amount. Hospice services and rates include:
- Skilled nursing care
- Personal care aide
- Medical social services
- Counseling or pastoral care
- Bereavement services
- Physical and occupational therapy
- Dietary counseling and volunteer coordination
All necessary medical equipment, supplies, drugs and biological are included in the fee schedule rate.
These services should be billed separately:
- Charges related to physician services, outpatient radiation therapy and chemotherapy used to control distressing symptom
- Treatment for conditions unrelated to the terminal illness
- Enteral feedings
- Total Parenteral Nutrition (TPN)
- Medically necessary diagnostic services
Coding & Billing Guidelines
Hospice services, except for related physician services, are billed under the hospice National Provider Identifier (NPI) on a UB-04 Claim Form. If a patient is admitted to an acute hospital for general inpatient care or inpatient respite care, the services must be billed by hospice under the hospice NPI, not the acute hospital NPI. A hospice may provide follow-up care to the family after the death of the patient, but these services are not separately billable.
The type of bill (TOB) used for hospice services is 81X for a freestanding, non-hospital-based hospice, or TOB 82X for a hospital-based hospice.
The following revenue codes and HCPCS codes must be submitted for reimbursable hospice services. The units used should reflect the type of service provided as noted in the code definitions. Claims will be rejected to the provider if the billing requirements for revenue codes and HCPCS codes are not met.
Revenue Code
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Definition
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HCPCS
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Definition
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Units
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0651
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Routine home care
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T2042
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Hospice Routine Home Care; per diem
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# Of days
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0652
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Continuous home care
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T2043
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Hospice Continuous Home Care; per hour
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# Of hours
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0655
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Inpatient respite care
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T2044
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Hospice Inpatient Respite Care; per diem
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# Of days
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0656
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General inpatient care- non-respite
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T2045
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Hospice General Inpatient Care; per diem
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# Of days
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0659
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Other hospice service - use for respite home care
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S9125
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Respite Care, in the home, per diem
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# Of days
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0651
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Routine home care
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Q5001
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Hospice or Home Health in the Home; per diem
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# Of days
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0651
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Routine home care
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Q5002
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Hospice/Home Health in Assisted Living Facility; per diem
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# Of days
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0651
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Routine home care
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Q5003
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Hospice in Nursing Long Term Care Facility (LTC) or Non-skilled Nursing Facility (NF); per diem
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# Of days
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0651
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Routine home care
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Q5004
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Hospice in Skilled Nursing Facility (SNF); per diem
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# Of days
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0656
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General inpatient care- non-respite
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Q5005
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Hospice, Inpatient Hospital; per diem
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# Of days
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0656
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General inpatient care- non-respite
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Q5006
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Hospice in Inpatient Hospice Facility; per diem
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# Of days
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0656
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General inpatient care- non-respite
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Q5007
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Hospice in Long Term Care Hospital (LTCH); per diem
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# Of days
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0656
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General inpatient care- non-respite
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Q5008
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Hospice in Inpatient Psychiatric Facility; per diem
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# Of days
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0651
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Routine home care
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Q5009
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Hospice/Home Health Place Not Otherwise Specified (NOS); per diem
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# Of days
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This policy does not apply to Federal Employee Program (FEP) members.
Limitations and Exclusions
While reimbursement is considered, payment determination is subject to, but not limited to:
- Group or Individual benefit
- Provider Participation Agreement
- Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
- Mandated or legislative required criteria will always supersede.
In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.
Cross References
Hospice Medical Policy
History
Date
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Updates
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12/23/2019
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Created Hospice Services reimbursement policy
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5/2/2022
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Added Q codes to list of codes that can be billed for Hospice Services. Removed language that Q codes are not reimbursable.
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