Eli's Hospice Insider

Prepare to change how you bill nursing visits.

Your nursing home patients won’t count against you when it comes to the new Service Intensity Add-on payment that takes effect Jan. 1.

The Centers for Medicare & Medicaid Services makes one big change from its SIA proposal from May: the extra payment for certain services furnished in the last seven days of life will apply regardless of site of service. In the proposed rule, CMS wanted to exclude SIA payments for patients in nursing homes (see Eli’s Hospice Insider, Vol. 8, No. 6).

“We applaud steps CMS has taken to modify the SIA policy so that it applies to all patients,” says Val Halamandaris of the National Association for Home Care & Hospice. “We believe that to do otherwise would deny patients equal access to care based on their place of residence,” Halamandaris says in a release.

According to the rule published in the Aug. 6 Federal Register, “to qualify for the SIA payment, the following criteria must be met:

(1) the day is a RHC level of care day;

(2) the day occurs during the last 7 days of life (and the beneficiary is discharged dead); and,

(3) direct patient care is provided by an RN or a social worker.”

The SIA payment rate will equal the Continuous Home Care hourly payment rate, multiplied by the amount of direct care provided by an RN or SW for up to four hours total, per day, CMS explains in the rule. Medicare will pay the SIA payment on top of the per diem rate for the RHC level of care.

Billing change: The SIA applies only to RN visits, not Licensed Practical Nurse visits, CMS points out in the rule. Thus, CMS will create two separate G codes for billing skilled nursing — one for an RN and one for an LPN. Watch for details in upcoming transmittals.

But other than that, there shouldn’t be any billing changes required for SIA payments. “Hospices should submit claims per the established protocols, and the claims processing system will determine the SIA payment eligibility of the 7 days preceding death,” CMS instructs. “The SIA payment will be calculated by the number of hours (in 15-minute increments) of service provided by an RN or social worker during the last 7 days of life for a minimum of 15 minutes and up to 4 hours total per day.”

Phone Visits Don’t Cut It

What counts? “While the nature of the role of the social worker does facilitate interaction via the telephone, CMS will only pay an SIA for those social work services provided by means of in-person visits,” CMS says. Fiscal year 2013 hospice claims data analysis “shows that in the last 7 days of life only approximately 10 percent of beneficiaries received social work visits of any kind. Moreover, we also found that only about 13 percent of social work ‘visits’ are provided via telephone; therefore, the proportion of social work calls likely represents a very small fraction of visits overall in the last few days of life.”

Phone visits for RNs, requested by hospices in rural and frontier areas, won’t count toward SIA payments either, CMS clarifies.

Tip: And “visits for the pronouncement of death will not be included as eligible visits for SIA payments,” CMS says.

CMS keeps its discussion of the SNF change brief. “The payment of the SIA for additional RN and SW services during the last 7 days of life in these settings is appropriate and thus we are finalizing a policy that pays the SIA payment for patients that reside in a SNF/NF,” the agency says in response to comments on the proposed rule. “We will monitor the SIA based on claims data and continue to investigate whether a differential site of service payment could be an appropriate mechanism to address ... concerns.”

“We applaud CMS for including SIA payment for all patients in the last seven days of life, regardless of their place of residence,” says Jonathan Keyserling of the National Hospice & Palliative Care Organization in a release.

While CMS proved open to making the SNF change, it shoots down a number of other requests to revise the SIA payment.

For example: Some commenters wanted SIAs for the first, resource-intensive days of a hospice episode. “There is increased resource use during the first 2 days of an election,” CMS allows in the rule. But “we are not proposing an additional SIA payment for the first or second day of a hospice election when the length of stay is beyond 7 days. The SIA payment for the last 7 days of life will provide additional reimbursement to help to mitigate the higher costs for stays lasting less than the median length of stay, where spreading out the initial costs of the first 2 days of the election over a smaller number of days may not be enough to make the overall stay profitable,” the agency reasons.

Other commenters wanted other discipline visits to count toward the SIA, such as chaplain, LPN and therapist visits. “The services rendered by all hospice professionals, including LPNs, are extremely valuable,” CMS allows. But “the primary goal of the SIA policy is to promote the highest-quality, skilled care to beneficiaries at the end of life. Given that RNs provide higher-skilled services ... and social workers provide a skilled level of support for both the patient and family, CMS will only pay an SIA amount for those services rendered by RNs and social workers.” The RHC rate should cover other services, CMS adds.

CMS isn’t closing the door on the matter, however. “In the future, we will re-evaluate whether the inclusion of services provided by LPNs for the SIA is warranted and re-assess the policies and payments around the CHC level of care as well as other facets of the Medicare Hospice Benefit,” the agency pledges in the rule.

No man’s land: Hospices furnishing care above the SIA four-hour limit and below the CHC eight-hour floor are still out of luck for additional reimbursement. “The RHC rate level of care plus the SIA payment for services up to 4 hours will provide sufficient payment to cover the increased cost of patient care,” CMS maintains. “If a patient’s needs intensify further ... hospices will still be able to provide the CHC level of care for 8 hours of service and beyond as well as utilize the other levels of hospice care as appropriate.”

Good news: CMS shot down a call to make SIA visits tougher to claim. “No additional documentation will be required in order to receive the SIA payment,” the agency says. “We appreciate the concern that some hospices may attempt to capitalize on extra payments made possible through the SIA policy. CMS will certainly continue to monitor hospice behavior for any concerning patterns as well as any impact to future payment updates. However ... providing payment for increased services at the end of life is consistent with the goal of responding to and providing for intensified patient needs.”

Bottom line: With SIAs, “we strive to encourage the hospice to provide skilled care in a patient’s most intense moments of need by dispersing additional payment for actual services rendered by the appropriate skilled staff,” CMS stresses.

Note: See CMS’s fact sheet about the final rule at www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-7-31-2.html.