Billing codes must specify RN vs. LPN January 1st

Huddle up, hospice and Home Health providers!

Come January 1, 2016, hospice and home health claims must specify whether an RN or LPN delivered the skilled nursing service on each line item.

If you needed more evidence that scrutiny of the hospice industry is the healthcare industry with more rapidly increasing scrutiny than other providers who bill Medicare, you’ll find it in Change Request 9369, dated October 16, 2015.

Details appear in italicized red in the Transmittal 3378 of the CMS Medicare Claims Processing Manual. But here are the basics, in Medicare’s own words:

“This Change Request creates new codes to distinguish whether a Registered Nurse (RN) or a Licensed Practical Nurse (LPN) provided hospice or home health services.”

That’s right!

As part of CMS’ stated response to industry requests that hospices receive additional payment for patients’ more intense end-of-life needs, Medicare needs to know which 15-minute increments of care LPNs performed and which 15-minute increments of care RNs performed.

G0154 remains the skilled nursing billing code for services provided through December 31, 2015. But as of January 1, 2016, G0299 is the billing code for RN services and G030 is the billing code for LPN services.

Just in case you missed the other details of the SIA published in the CY 2016 Hospice Final Rule, here’s the nutshell version.

The SIA payment is in addition to the per diem Routine Home Care (RHC) rate, for registered nursing and medical social worker visits provided during the last seven days of life during hospice election.

CMS stated in the rule that “services rendered by all hospice professionals, including LPNs, are extremely valuable.” But “the primary goal of the SIA policy is to promote the highest-quality, skilled care to beneficiaries at the end of life.”

RNs are more “highly trained clinicians with commensurately higher payment rates” who are better suited (then LPNs) to continually assess and meet the needs of actively dying patients and their families as required by hospice CoPs [§418.56(a)(1)].

CMS-commissioned analysis of FY 2013 & 2014 claims data shows that more than 27% of hospice beneficiaries received no skilled services on the day they died. And on any given day of the last 7 days of life, nearly 50 percent of hospice patients received no skilled care.

 CMS describes the SIA as an incentive for hospices to provide more skilled (specifically RN and MSW) services at the end of life, when “patient needs typically surge and more intensive services are warranted.” The SIA does not apply to services rendered by other professionals.

See the document for the specific equation to calculate the SIA. But know that it begins with RN and MSW in-person services provided for a minimum of 15 minutes and a maximum of 4 hours per day with the patient or family. In addition, the time of a social worker’s phone calls is not eligible.