Description
This policy addresses reimbursement for hospice services.
Definitions
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.
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 symptoms
- Treatment for conditions unrelated to the terminal illness
- Enteral feedings
- Total Parenteral Nutrition (TPN)
- Medically necessary diagnostic services
Billing Instructions
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. BCBSND will not reimburse HCPCS (Q5001-Q5009) for hospice services. If HCPCS within the “Q” code range are billed to BCBSND, the claim will be rejected for resubmission with the appropriate “T” or “S” code(s).
| Revenue Code |
Definition |
HCPCS Code |
Definition |
Units |
| 0651 |
Routine Home Care |
T2042 |
Hospice Routine Home Care; per diem |
Number of days |
| 0652 |
Continuous Home Care |
T2043 |
Hospice Continuous Home Care; per hour |
Number of hours |
| 0655 |
Inpatient Respite Care |
T2044 |
Hospice Inpatient Respite Care; per diem |
Number of days |
| 0656 |
General Inpatient Care – Non-Respite |
T2045 |
Hospice General Inpatient Care; per diem |
Number of days |
| 0659 |
Other Hospice Service – Use for Respite Care |
S9125 |
Respite Care, in the home, per diem |
Number of days |
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 Reference
Revisions
| Date |
Updates |
| 12/23/2019 |
Removed reimbursement guidelines from Provider Manual and created Hospice Services reimbursement policy. |