Hospice Billing

Hospice Room and Board Denials

Medicare does not pay the room and board fees for hospice beneficiaries that reside in a SNF or a nursing facility (NF), as these charges are statutorily excluded from Medicare coverage. However, these charges may be paid by another insurer. If the patient has Medicaid, the state Medicaid agency may pay the hospice the daily amount allowed by the state for room and board while the patient is receiving hospice care, and the hospice would then pay the facility. Room and board services include:

  • The performance of personal care services
  • Assistance in activities of daily living
  • Socializing activities
  • Administration of medication
  • Maintaining the cleanliness of a resident’s room, and
  • Supervising and assisting in the use of DME and prescribed therapies

Some of these insurers require a room and board denial from Medicare before paying the hospice. In the past, National Government Services issued letters to providers, upon request, that explained that the room and board charges are excluded from Medicare coverage for beneficiaries who elect hospice and reside in a SNF or NF. However, effective 4/1/2011, this process has changed. Hospice providers may now submit claims for the room and board charges in order to bill the other insurer for these charges.

Billing

When you need a room and board denial from Medicare in order to bill another insurer, providers should submit their covered hospice sequential claims as normal. The hospice should then submit a separate noncovered claim to Medicare that only includes the room and board charges, whenever possible. If it is not possible to submit a separate claim, the room and board charges can be submitted on your covered hospice sequential claim(s).

When submitting a claim for room and board charges only, in addition to the basic claim fields that are required for all hospice claims, the noncovered claim should include the following:

Claim Page One Description
TOB Valid Values:

810 Freestanding hospice
820 Hospital-based hospice
STMT DATES FROM Enter the same ‘from’ date that was reported on the covered sequential hospice claim
STMT DATES TO Enter the same ‘to’ date that was reported on the covered sequential hospice claim
ADMIT DATE Enter the date of the hospice election in the MMDDYY format
COND CODES Valid Value: 21

 

Claim Page Two Description
REV Valid Value: 0659
HCPC Valid Value: A9270
MODIFS Valid Value: GY
TOT UNIT Enter the total number of days for the statement period
TOT CHARGE Enter the room and board amount (the TOT CHARGE amount and the NCOV CHARGE amount should be the same)
NCOV CHARGE Enter the room and board amount (the TOT CHARGE amount and the NCOV CHARGE amount should be the same)
SERV DT Enter the same date that is entered in the STMT DATES FROM field

 

Claim Page Four Description
REMARKS Include remarks that explain the reason for the noncovered claim (e.g., “Room and Board denial request”)

 

When submitting a claim with both covered charges and the noncovered room and board charges, in addition to the claim information that is required for the covered hospice claim, the claim should also include the following line item information for the room and board charges:

Claim Page Two Description
REV Valid Value: 0659
HCPC Valid Value: A9270
MODIFS Valid Value: GY
TOT UNIT Enter the number of days during the statement period that the room and board charges were applied
TOT CHARGE Enter the room and board amount (the TOT CHARGE amount and the NCOV CHARGE amount should be the same)
NCOV CHARGE Enter the room and board amount (the TOT CHARGE amount and the NCOV CHARGE amount should be the same)
SERV DT Enter the first date that room and board charges were applied for the statement period

 

Claim Page Four Description
REMARKS Include remarks that explain the reason for the noncovered claim (e.g., “Room and Board denial request”)