(Medicare Claims Processing Manual)

EOL Day 2  Add-on Units  x(2) 71-72 Input item: The sum of the units associated with revenue codes 055x (if G0299 present) and 056x (other than 0569) on the date of death minus 1 day. No units input if the lines are not associated with routine home care (revenue code 0651)  EOL Day 3  Add-on Units  x(2) 73-74 Input item: The sum of the units associated with revenue codes 055x (if G0299 present) and 056x (other than 0569) on the date of death minus 2 days. No units input if the lines are not associated with routine home care (revenue code 0651)  EOL Day 4  Add-on Units  x(2) 75-76 Input item: The sum of the units associated with revenue codes 055x (if G0299 present) and 056x (other than 0569) on the date of death minus 3 days. No units input if the lines are not associated with routine home care (revenue code 0651)  EOL Day 5  Add-on Units  x(2) 77-78 Input item: The sum of the units associated with revenue codes 055x (if G0299 present) and 056x (other than 0569) on the date of death minus 4 days. No units input if the lines are not associated with routine home care (revenue code 0651)  EOL Day 6  Add-on Units  x(2) 79-80 Input item: The sum of the units associated with revenue codes 055x (if G0299 present) and 056x (other than 0569) on the date of death minus 5 days. No units input if the lines are not associated with routine home care (revenue code 0651)  EOL Day 7  Add-on Units  x(2) 81-82 Input item: The sum of the units associated with revenue codes 055x (if G0299 present) and 056x (other than 0569) on the date of death minus 6 days. No units input if the lines are not associated with routine home care (revenue code 0651)  Filler  x(10)  83-92  QIP- REDUCTION- IND x 93 Input item: An indicator of whether the hospice's payments are subject to the 4%  reduction for not reporting quality data. Copied from field 74 on the Outpatient Provider Specific File. Valid values: blank = no reduction, 1 = 4%  reduction applies.  REV1  X(4)  94-97 Input item: Revenue code 0651 (if present) copied from the claim.  HCPC1  X(5)  98-102 Input item: HCPCS G code associated with revenue code 0651, copied from the claim. Line Item DOS1  9(8) 103-110 Input item: The line item  date of service associated with revenue code 651, copied from the claim.  UNITS1  9(7) 111-117 Input item: The number of units associated with revenue code 0651, copied from the claim. This represents the number of days of routine home care to be paid.  THEIR -PAY-  CHG1  9(6)V99  118-125 Output item: The total payment to be made on the revenue code 0651 line.  REV2  X(4)  126-129 Input item: Revenue code 0652 (if present) copied from the claim.  HCPC2  x(5) 130-134 Input item: HCPCS G code associated with revenue code 0652, copied from the claim. Line Item DOS2  9(8) 135-142 Input item: The line item  date of service associated with revenue code 652, copied from the claim.  UNITS2  9(7) 143-149 Input item: The number of units associated with revenue code 0652, copied from the claim. This represents the number of 15 minute increments of continuous home care to be paid.  THEIR -PAY-  CHG2  9(6)V99  150-157 Output item: The total payment to be made on the revenue code 0652 line.  REV3  X(4)  158-161 Input item: Revenue code 0655 (if present) copied from the claim.  HCPC3  x(5) 162-166 Input item: HCPCS G code associated with revenue code 0655, copied from the claim. Line Item DOS3  9(8) 167-174 Input item: The line item date of service associated with revenue code 655, copied from the claim.  UNITS3  9(7) 175-181 Input item: The number of units associated with revenue code 0655, copied from the claim. This represents the number of days of inpatient respite care to be paid.  THEIR -PAY-  CHG3  9(6)V99  182-189 Output item: The total payment to be made on the revenue code 0655 line.  REV4  X(4)  190-193 Input item: Revenue code 0656 (if present) copied from the claim.  HCPC4  x(5) 194-198 Input item: HCPCS G code associated with revenue code 0656, copied from the claim. Line Item DOS4  9(8) 199-206 Input item: The line item  date of service associated with revenue code 656, copied from the claim.  UNITS4  9(7) 207-213 Input item: The number of units associated with revenue code 0656, copied from the claim. This represents the number of days of general inpatient care to be paid.  THEIR -PAY-  CHG4  9(6)V99  214-221 Output item: The total payment to be made on the revenue code 0656 line.  NA Day 1 Add-on Pay 9(6)V99  222-229 Output item:  Not used  NA Day 2 Add-on Pay 9(6)V99  230-237 Output item:  Not used  EOL Day 1  Add-on Pay  9(6)V99  238-245 Output item: Payment associated with the corresponding ADD- ON-UNITS field (units multiplied by the CHC rate, up to a limit of 16 units)  EOL Day 2  Add-on Pay  9(6)V99  246-253 Output item: Payment associated with the corresponding ADD- ON-UNITS field (units multiplied by the CHC rate, up to a limit of 16 units)  EOL Day 3  Add-on Pay  9(6)V99  254-261 Output item: Payment associated with the corresponding ADD- ON-UNITS field (units multiplied by the CHC rate, up to a limit of 16 units)  EOL Day 4  Add-on Pay  9(6)V99  262-269 Output item: Payment associated with the corresponding ADD- ON-UNITS field (units multiplied by the CHC rate, up to a limit of 16 units)  EOL Day 5  Add-on Pay  9(6)V99  270-277 Output item: Payment associated with the corresponding ADD- ON-UNITS field (units multiplied by the CHC rate, up to a limit of 16 units)  EOL Day 6  Add-on Pay  9(6)V99  278-285 Output item: Payment associated with the corresponding ADD- ON-UNITS field (units multiplied by the CHC rate, up to a limit of 16 units)  EOL Day 7  Add-on Pay  9(6)V99  286-293 Output item: Payment associated with the corresponding ADD- ON-UNITS field (units multiplied by the CHC rate, up to a limit of 16 units)  PAY- AMT  9(6)99  294-301 Output item: The sum of all payment amounts returned on this record.  RTC  XX 302-303 Output item: A return code set by Pricer to define the payment circumstances of the claim or an error in input data.    Payment return codes:                                                00 Home rate returned  73 Low RHC rate applies to all RHC  74 Low RHC rate with EOL SIA  75 High RHC rate applies to some or all RHC  77 High RHC with EOL SIA        No rate return error codes:      10 Bad units  20 Bad units2<8  30 Bad CBSA code  40 Bad hospice wage index from CBSA file  50 Bad bene wage index from CBSA  file  51 Bad provider number  High RHC Days  99 304-305 Output item: The number of high RHC days applied to the claim.  This number is placed on the claim as a value code 62 amount.  Low RHC Days  99 306-307 Output item: The number of low RHC days applied to the claim.  This number is placed on the claim as a value code 63 amount.  FILLER x(8) 308-315   130.2 Decision Logic Used by the Pricer on Claims    (Rev. 12083; Issued: 06- 15-23; Effective: 05 -15-23; Implementation: 07- 17-23)  The following components are used by the Hospice Pricer to determine the Hospice payment rate:   Wage Index   Labor and Non -Labor Amounts for each level of care rate  - Routine Home Care (RHC) rates days 1 thru 60  - Routine Home Care (RHC) rates days 60+  - Continuous Home Care (CHC) rates  - Inpatient Respite Care (IRC) rates  - General Inpatient Care (GIP) rates   Service Intensity Add- on (SIA) rates  These components are updated in the Hospice Pricer annually. Whenever the Hospice Pricer is updated, Medicare also publishes a Recurring Update Notification to inform providers and A/B MACs (HHH) about the changes.  On each input record, Pricer performs the following calculations:  1. Determine the payment rate for the RHC level of care REV1 by multiplying the labor portion of the RHC payment rate by the associated BENE CBSA wage index and sum with the non- labor portion.  The labor portion plus the non- labor portion, multiplied by the number of RHC days determines the payment amount.  There are high/low RHC labor and non- labor share rates. The RHC low rate is applied to all RHC days for service beyond the 60th day (calculated by looking at the span between the ADMISSION DATE field and the LINE ITEM DOS1 date field plus NA DAY 1 ADD- ON UNITS). The RHC high rates are applied to service on the 60th day or earlier.   If EOL Day 1 Add- on Units are present then SIA payment will be made. The payment will be equal to the CHC hourly rate, multiplied by the hours of nursing or social worker services provided (up to four hours total) that occurred on the day of service or a t otal of 16 units per day for the final seven days of life.   2. Determine the payment rate for the CHC level of care REV2 by multiplying the labor portion of the CHC payment rate by the associated BENE CBSA wage index and sum with the non- labor portion.  The labor portion plus the non- labor portion, multiplied by the number of CHC hours (UNITS2 divided by 4) determines t he payment amount.  3. Determine the payment rate for the IRC level of care REV3 by multiplying the labor portion of the IRC payment rate by the associated PROV CBSA wage index and sum with the non- labor portion.  The labor portion plus the non- labor portion, multiplied by the number of IRC days determines the payment amount.  4. Determine the payment rate for the GIP level of care REV4 by multiplying the labor portion of the GIP payment rate by the associated PROV CBSA wage index and sum with the non- labor portion.  The labor portion plus the non- labor portion, multiplied by the n umber of GIP days determines the payment amount.  5. Calculate the total claim payment by adding all the THEIR -PAY- CHRG fields plus the SIA payment amount total. This is informational only. The clams processing systems uses the THEIR -PAY-  CHRG fields to make payment.  Note: Pricer reduce payment by 4%  if the hospice does not submit quality data. A value of 1 in the QIP REDUCTION IND field indicates that the hospice is subject to the 4%  payment reduction due to not reporting required quality data.