Hospice Payment Reform

Effective October 29, 2017, the NC Department of Health and Human Services (DHHS) will implement Hospice Payment Reform in NCTracks based on guidance from the Centers for Medicare & Medicaid Services (CMS). The reform consists of service intensity add-on (SIA) payments for hospice social worker (SW) and registered nurse (RN) visits provided during the last seven days of life when provided during routine home care. Payment reform also includes the implementation of 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, based on paid claims history. This two-tiered rate calculation is effective for dates of service on and after January 1, 2016. This was first announced in the January 2016 Medicaid Special Bulletin.

  1. Specific payment rules apply for patients discharged from hospice within the first 60 days and later readmitted. Note the two-tier pricing and discharge rules are recipient specific. Change in hospice provider does not impact pricing.
  2. Claims that are billed out of sequence and are determined to have overpaid based on subsequent claim receipts for prior dates of service may be voided. Providers will be responsible for resubmission.
  3. Among the changes associated with Hospice Payment Reform, and directly related to the SIA payment, is the discontinuation of bill status code 20 to denote the death of a hospice patient. Per Medicare guidelines, hospice claims must bill using a hospice-specific patient status code when the patient has expired. Effective October 29, 2017, valid discharge codes denoting death of the patient for hospice claims are:

40 - Expired at home

41 - Expired at medical facility

42 - Expired place unknown

Important: The seven-day service intensity add-on must be billed on the same claim that is denoting the patient expiration status code.

These changes are specific to Medicaid primary claims. For additional information, including links to the hospice fee schedule and clinical coverage policy, refer to the Hospice Services page on the NC Division of Medical Assistance website. There will also be a new Hospice Job Aid in SkillPort on the secure NCTracks provider portal. An announcement will be posted on the Provider Training page of the NCTracks provider portal when the Job Aid is available.

Hospice claims paid with a date of service on or after January 1, 2016, and processed before October 29, 2017, will be reprocessed later. An additional provider communication will be published when the hospice claims affected by this update are scheduled to be reprocessed.