HI 225 Ch07 pp ts.opps.ab202017

1. © 2018 American Health Information Management Association
© 2018 American Health Information Management Association
Principles of Healthcare Reimbursement
Sixth Edition
Anne B. Casto, RHIA, CCS

2. © 2018 American Health Information Management Association
Chapter 7
Ambulatory and Other Medicare-Medicaid
Reimbursement Systems
• Learning Objectives
– Explain the elements of the hospice services
payment system
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3. © 2018 American Health Information Management Association
Hospice Services Payment System
• Key Terms
– Hospice
– Palliative care
– Respite care
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4. © 2018 American Health Information Management Association
Hospice
Interdisciplinary
approach to
deliver medical,
nursing, social,
psychological,
emotional, and
spiritual services
through a broad
spectrum of
professional and
other caregivers
Hospice… a
comprehensive
holistic
approach to
healthcare that
recognizes
patients’
impending
deaths
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Service provided to
terminally-ill patients
and their families
Palliative services
designed to relieve
pain and suffering
Patients have
decided to forego
curative treatments

5. © 2018 American Health Information Management Association
Hospice Services
Medicare Covered Services
Physicians’ services Skilled nursing care
Medical equipment Medical supplies
Drugs and biologicals for pain control
and symptom management
Physical, occupational, and speech
therapy
Counseling (dietary, spiritual,
bereavement, and other services)
Home health aide and homemaker
services
Inpatient respite care (relief for
caregiver)
Other services necessary for palliation
and management
of terminal illness
Short-term inpatient acute care
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Hospice Care Team
Hospice
Physician
Nurse
Counselor
Social
Work
Therapist
Aides
Volunteers
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Hospice Service Delivery
Patient
homes
Free-standing
organizations
Units of acute
care inpatient
hospitals
Units of
skilled nursing
facilities
Provided by
home health
agencies
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8. © 2018 American Health Information Management Association
Hospice Benefit
Coverage
Requirements
• Two
physicians
certify
patient is
terminally ill
and has </=
6 months
• Beneficiary
has elected
hospice
benefit in
writing
• Written plan
of care
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1st benefit
period
• 90 days
2nd benefit
period
• Recertification for second 90-day benefit
period
3rd benefit
period
• Prior to 180th day, hospice provider must
have face-to-face with patient
• May be recertified for unlimited number
of 60-day periods, each with preceding
face-to-face encounter

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Hospice Cost-Sharing
• No deductible
• Prescriptions – 5% coinsurance (not to
exceed $5) for each outpatient prescription
• Inpatient respite care – 5% of Medicare’s
respite care payment per day, not to
exceed Part A inpatient deductible ($1,340
FY 2018)
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10. © 2018 American Health Information Management Association
Reimbursement
• Per diem reimbursement methodology
• Four levels of hospice care known as
categories
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RHC
• Routine
home care
• $192.78
CHC
• Continuous
home care
• $976.42
IRC
• Inpatient
respite care
• $172.78
GIC
• General
inpatient
care
• $743.55
Daily rate includes: visit cost, on-call services, care planning, drugs
and medical equipment, supplies related to a terminal illness and
transportation

11. © 2018 American Health Information Management Association
Reimbursement
• Daily rate is not related to amount of
services
• Payment for a day with no services is
equal to a day with many services
• Daily rate does not include costs of
services unrelated to terminal illness
(Medicare Part A and B, as applicable)
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12. © 2018 American Health Information Management Association
Wage Index Adjustment
• Category base rates adjusted for geographic factors and
intensity of human resources
• Geographic location: CBSAs, urban and nonurban
– Labor portion for varying wage indexes across US
– Non-labor portion for varying costs of supplies, equipment, and
other services across US
• Intensity of human resources varies by category
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RHC
• Labor
portion
68.71%
CHC
• Labor
portion
68.71%
IRC
• Labor
portion
54.13%
GIC
• Labor
portion
64.01%

13. © 2018 American Health Information Management Association
Service Intensity Add-on
• Extended care provided during the
beneficiary’s last seven days of life
– Covers nursing and/or social work care
– Up to four hours of services per day
– Reimbursement is by hour; uses CHC hourly
rate (FY 2018 = $39.88).
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14. © 2018 American Health Information Management Association
Payment Steps
Assign
Category
Wage index
category rate
Multiply
number of
days by
adjusted
category rate
Sum the daily
payment
amounts
together
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15. © 2018 American Health Information Management Association
Hospice Provider Services
Limits
• Number of days of inpatient care (GIC)
may not exceed 20% of total patient care
days
• Aggregate cap amount
– Total payments for the provider may not
exceed the cap. 2018 cap = $28,689.04
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