Service Intensity Add-on Payment
Table of Contents
- Service Intensity Add-on Payment
- HCPCS
- Example 1 LIDOS 1/30/20XX
- Example 2 LIDOS 1/1/20XX
- Example 3 LIDOS 1/1/20XX
- Example 4: Services That are Reported with the PM Modifier
- Related Content
Service Intensity Add-on Payment
Effective 1/1/2016, CR 9201 implements hospice SIA payments for direct patient care provided by a social worker or an RN during the last seven days of life when provided during routine home care. The SIA payment is in addition to the RHC rate. For claim(s) date of service on or after 1/1/2016, an SIA payment maybe made for social worker and/or registered nursing visits when the following criteria are met:
- The day is an RHC level of care day.
- The day occurs during the last seven days of life (and the beneficiary is discharged deceased).
- Service provided by an RN or social worker that day for at least 15 minutes and up to four hours total.
- The service is not provided by a social worker via telephone.
HCPCS
The SIA payment is only payable for those nursing services that are provided by a registered nurse. The SIA policy necessitated the creation of two new G-codes to differentiate between service provided by an RN and an LPN or an LVN. Effective 1/1/2016, the following codes will be reported with the revenue code 055X (skilled nursing) to describe the nursing visits provided:
- G0299 ‑ Direct skilled nursing services of an RN in the home health or hospice setting, each 15 minutes
- G0300 ‑ Direct skilled nursing services of an LPN in the home health or hospice setting, each 15 minutes
- The SIA payment is only payable for social worker visits; phone calls are not eligible for an SIA payment. The following HCPCS code would be reported with the revenue code 056X (medical social services):
- G0155 ‑ Services of clinical social worker in home health or hospice settings, each 15 minutes
Special Note: The SIA payment will only apply to visits that occur prior to death. Visits reported with the PM modifier will not receive an SIA payment. See example 3 below.
Payment Calculation
The SIA Payment amount shall equal:
- The number of hours (in 15-minute increments) of service provided by an RN or social worker during the last seven days of life up to four hours total per day;
- Multiplied by the current hospice CHC hourly rate per 15 minutes X visit units (not greater than 16)
- Adjusted for geographic differences in wages.
The SIA daily payment calculated by the hospice PRICER will be entered on the first applicable visit line item for each date of service payable.
CBSA
For claim submission, hospices will use either the CBSA code or the special code 50XXX number found in column L of the wage index file. The special 50XXX number will be applicable to FY2016 claims only. Hospices need to use the correct CBSA or alternate 50XXX number. Our claims processing systems will match the correct wage index with the CBSA or alternate 50XXX number submitted on the claim. Hospice will not need to calculate the transition wage index. Once the one-year transition to the new area delineations is over, the 50XXX numbers will not be needed. Visit the CMS website to determine your CBSA.
Calculating Days
The Medicare system will calculate the days and the discipline reporting that is eligible to receive the SIA payment and apply the payment to the first line item. Medicare does not require any special coding by the provider other than the normal reporting.
How to Locate Your CHC Rate for Your Geographic Area
CHC rates can be found on our website: click on Claims & Appeals > Fee Schedules and Pricers > Hospice Payment Rates
On the excel spreadsheet, locate the tab for your state at the bottom of the page and then locate your geographic area and the CHC rate for your area.
Example 1 LIDOS 1/30/20XX
This example illustrates how to calculate a single line item that is eligible for the SIA payment. The claim was billed for 22 days; however for the purpose of this example all other line items services have been removed. The beneficiary passed away on 1/31/20XX. This example demonstrates how to calculate a single line item for the SIA payment.
Line item 1 indicates the claim was billed for 22 days starting on 1/10/2016 at an RHC level of care in the patients home (Q5001).
Line 2 is a registered nursing visit (G0299) billed for 2 units (1 unit = 15 minutes) on 01/30/20XX. Two units equal 30 minutes.
- Calculate the time: 30 minutes =.50
- Find the wage adjusted rate for CHC using instructions above. The wage adjusted rate for CHC used in this example is $43.99. This rate is for demonstration purposes and will change each year according the adjusted rates.
- Multiply the wage adjusted rate for CHC by the total time.
Calculation: 43.99 X .50 (units billed) = $22.00.
- $22.00 X .98 (Sequestration) = $21.56. $21.56 will be reported on line item 2.
Example 2 LIDOS 1/1/20XX
This example illustrates how to calculate a SIA payment for two line items on a single date of service. In this example, the beneficiary had both a nursing and social worker visit on the same day prior to the beneficiary’s death. The nurse arrives at 9:50 a.m. and the patient is pronounced deceased at 10:00 a.m. The nurse provides post mortem care until 10:30 a.m. The social worker visited prior to the beneficiary’s death.
Line 1 shows the RHC rate (rev code 0651) in the patients home (HCPC Q5001) for one date of service 1/1/20XX.
Line 2 shows the reporting of the RN visit (HCPC G0299) for the 10 minutes (9:50 -10:00 a.m.) of nursing care provided prior to the beneficiaries death, and would be billed with one unit of service. Line 2 would be eligible for the SIA payment.
Line 3 shows a social worker visit for three units of service. The services were rendered prior to the beneficiary’s death.
Line 4 shows the reporting of the registered nurse visit that occurred after the beneficiary expired (10:00 a.m. to 10:30 a.m.), and is billed for 2 units with a PM modifier. This line would not be eligible for the SIA payment.
How to calculate for the SIA payment
- Calculate the total time for the nurse and social worker visit (add line 2 and 3 = 4 units). 4 units =1
- Find the wage adjusted rate for CHC per instructions above. The wage adjusted rate for the CHC used in this example is $43.99.
- Multiply the wage adjusted rate for CHC by the total time.
Calculation: 43.99 X 1 hour (total units from line 2 and 3) = $43.99
- 43.99 X .98(Sequestration) = $43.11. $43.11 would be reported on line 2. Note: The payment for line 2 and 3 will be reported on a single line (line 2).
Example 3 LIDOS 1/1/20XX
This example illustrates how to calculate the SIA payment for a single line item when the beneficiary dies on the date of service. In this example services were rendered prior to the beneficiary’s death and post mortem.
Line item 1 indicates the claim was billed for 22 days starting on 1/10/2016 at an RHC level of care in the patients home (Q5001).
In this example line 8 is an RN visit (G0299) billed for five units (1 unit = 15 minutes). Five units equals 1 hour and 15 minutes, which is equal to 1.25.
- Calculate the time: 1 hour and 15 minutes = 1.25
- Find the wage adjusted rate for CHC per instructions above. The wage adjusted rate for continuous home care used in this example is $43.99. This rate is for demonstration purposes and will change each year according the adjusted rates.
- Multiply the wage adjusted rate for CHC by the total time.
Calculation: 43.99 X 1.25 (units billed) = $54.99.
$54.99 X .98 (Sequestration) = $53.89. $53.89 would be reported on line 8.
Special Note: Line 9 shows a registered nursing visit (G0299), with the PM modifier. The PM modifier indicates the visit occurred post mortem. Visits that occur after death are not eligible for the SIA payment. Therefore, in this example only line 8 is eligible to receive an SIA. Therefore, in this example only line 8 is eligible to receive an SIA payment.
Visit Reporting for the SIA Payment
Background Information
CMS issued change request CR 6440 on 5/15/2009 that provided information for mandatory reporting of discipline visit reporting for beneficiaries in an RHC, CHC and inpatient respite care level of service. For all RHC, CHC and inpatient respite care billing, hospice providers must report each visit performed by nurses, aides and social workers who are employed by the hospice and their associated time per visit in the number of 15-minute increments, on a separate line.
CR 6440 provided instructions that when recording any visit or social worker phone call time, providers should sum the time for each visit or call, rounding to the nearest 15 minute increment. Providers should not include travel time or documentation time in the time recorded for any visit or call. Additionally, hospices may not include interdisciplinary group time in time and visit reporting.
To constitute a visit, the discipline, (as defined by the HCPCS code) must have provided care to the beneficiary. In addition the visit must be reasonable and necessary for the palliation and management of the terminal illness and related conditions as described in the patient’s plan of care.
Below is a reference chart to show the number of minutes and the units that may be billed for based on the number of minutes that care was provided to the beneficiary. It is the expectation that care was actually rendered to the beneficiary, meaning that it would be rare that a visit would only be two minutes. However, if the visit was two minutes you would round to the nearest 15 minutes and bill for 1 unit. Your documentation must reflect that care was provided to the beneficiary and the time must be reported in the documentation.
Time Reporting Chart
| Unit(s) | Time | Unit(s) | Time |
|---|---|---|---|
| 1 | <23 minutes | 6 | = 83 minutes to <98 minutes |
| 2 | = 23 minutes to <38 minutes | 7 | = 98 minutes to <113 minutes |
| 3 | = 38 minutes to <53 minutes | 8 | = 113 minutes to <128 minutes |
| 4 | = 53 minutes to <68 minutes | 9 | = 128 minutes to <143 minutes |
| 5 | = 68 minutes to <83 minutes | 10 | = 143 minutes to <158 minutes |
Discipline Reporting for Service Intensity Add-on Payment
CR 9201 implemented service intensity add-on payments for hospice social worker and registered nurse visits provided during the last seven days of life when provided during RHC.
When all criteria is met the SIA payment amount shall equal the number of hours (in 15 minute increments) of service provided by a registered nurse and/or social worker during the last seven days of life for a minimum of 15 minutes and up to four hours total per day. The rules for discipline time reporting were not changed with the implementation of CR 9201. It is the expectation that you round to the nearest 15 minutes when care provided is less than 15 minutes.
A unit of zero cannot be entered on a discipline reporting line or the claim will reject. Therefore, providers will continue to use the instructions of CR 6440 to report discipline line reporting. Minutes must be rounded to the nearest 15 minute increment.
Lines that are reported with a PM modifier will indicate a post mortem visit and are not be eligible for the SIA payment.
Example 4: Services That are Reported with the PM Modifier
The nurse arrives at 9:50 a.m. and the patient is pronounced deceased at 10:00 a.m. The nurse provides post mortem care until 10:30 a.m.
Line 1 shows the RHC rate (rev code 0651) in the patients home (HCPCS Q5001) for one date of service 1/1/20XX.
Line 2 shows the RN visit (HCPCS G0299) for 45 minutes (10:00-10:45 a.m.) equals three units. Since the nurse arrived to find the patient deceased, and make the pronouncement of death, no skilled nursing care was provided to the patient, and the time would be reported with the PM modifier.
Line 3 shows the social worker visit (HCPCS G0155) for 1 hour and 15 minutes. The social worker arrived prior to the pronouncement of the patient’s death. However, since the patient was obviously deceased no direct care no direct patient care was rendered by the social worker. The social worker provided comfort and grief counseling to the beneficiary’s family. At this time, per CMS policy the social worker time would be reported with a PM modifier, since direct patient care was not rendered due to the beneficiary being deceased.
Note: Services reported with a PM modifier are not eligible for the SIA payment.
Related Content
- MLN Matters® Article: MM11876 Update to Hospice Payment Rates, Hospice Cap, Hospice Wage Index and Hospice Pricer for FY 2021
- MLN Matters® Article: MM9201 Implementation of the Hospice Payment Reforms
- CMS IOM Publication, 100-04, Medicare Claims Processing Manual, Chapter 11 – Processing Hospice Claims, Sections 30.2 and 30.2.2
Revised 5/2/2018