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Hospice ServicesHospice Services

ARCHIVAL USE ONLY Refer to the Online Handbook

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DIVISION OF HEALTH CARE FINANCING WISCONSIN MEDICAID AND BADGERCARE PROVIDER SERVICES 6406 BRIDGE ROAD MADISON WI 53784 Jim Doyle Governor Telephone: 800-947-9627 State of Wisconsin 608-221-9883 Helene Nelson www.dhfs.state.wi.us/medicaid Secretary Department of Health and Family Services www.dhfs.state.wi.us/badgercare

Wisconsin.gov

M E M O R A N D U M

DATE: January 3, 2006 TO: Wisconsin Medicaid-Certified Hospice Providers FROM: Mark Moody, Administrator Division of Health Care Financing SUBJECT: Wisconsin Medicaid Hospice Services Handbook The Division of Health Care Financing is pleased to provide a copy of the new Hospice Services Handbook to providers. This handbook articulates current Medicaid policies found in Wisconsin Administrative Code, HFS 101-108, as they apply to hospice services. The Hospice Services Handbook incorporates current Medicaid hospice policy information into a single reference source. The handbook replaces the Part S, the Hospice Handbook, originally issued on August 1, 1990, and the following service-specific Wisconsin Medicaid and BadgerCare Updates: • The November 1996 Update (96-43), titled “Hospice Services: Patient Liability, Required Forms, and

Commonly Asked Questions.” • The June 1999 Update (99-21), titled “Hospice handbook replacement pages.” • The November 2000 Update (2000-51), titled “Billing personal care for hospice recipients.” • The June 2003 Update (2003-32), titled “Changes to patient liability billing due to HIPAA.” • The June 2003 Update (2003-38), titled “Changes to local codes and paper claims for hospice

services as a result of HIPAA.” • The August 2003 Update (2003-93), titled “Effective dates for claims submission changes as a result

of HIPAA for hospice services.” • The December 2003 Update (2003-161), titled “Hospice reimbursement rate increase.” • The July 2004 Update (2004-57), titled “Submitting Adjustment Requests for Retroactive Rate

Changes.” • The November 2004 Update (2004-85), titled “Hospice Reimbursement Rate Increase.”

This handbook does not replace the All-Provider Handbook, all-provider Updates, the Wisconsin Administrative Code, or Wisconsin Statutes. Subsequent changes to hospice service policies will be published first in Updates and later in revisions to the Hospice Services Handbook.

Additional Copies of Publications The Wisconsin Medicaid Web site, dhfs.wisconsin.gov/medicaid/, contains additional information for all Medicaid providers, service-specific information, and electronic versions of the Hospice Services Handbook and the All-Provider Handbook. Providers who have questions about the information in this handbook may call Provider Services at (800) 947-9627 or (608) 221-9883.


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CContacting Wisconsin Medicaid

Web Site dhfs.wisconsin.gov/

The Web site contains information for providers and recipients about the following:

Available 24 hours a day, seven days a week

• Program requirements. • Publications. • Forms.

• Maximum allowable fee schedules. • Professional relations representatives. • Certification packets.

Automated Voice Response System (800) 947-3544 (608) 221-4247

The Automated Voice Response system provides computerized voice responses about the following:

Available 24 hours a day, seven days a week

• Recipient eligibility. • Prior authorization (PA) status.

• Claim status. • Checkwrite information.

Provider Services (800) 947-9627 (608) 221-9883

Correspondents assist providers with questions about the following: • Clarification of program

requirements. • Recipient eligibility.

• Resolving claim denials. • Provider certification.

Available: 8:30 a.m. - 4:30 p.m. (M, W-F) 9:30 a.m. - 4:30 p.m. (T)

Available for pharmacy services: 8:30 a.m. - 6:00 p.m. (M, W-F) 9:30 a.m. - 6:00 p.m. (T)

Division of Health Care Financing Electronic Data Interchange Helpdesk

(608) 221-9036 e-mail: [email protected]

Correspondents assist providers with technical questions about the following: Available 8:30 a.m. - 4:30 p.m. (M-F) • Electronic transactions. • Companion documents.

• Provider Electronic Solutions software.

Web Prior Authorization Technical Helpdesk (608) 221-9730

Correspondents assist providers with Web PA-related technical questions about the following:

Available 8:30 a.m. - 4:30 p.m. (M-F)

• User registration. • Passwords.

• Submission process.

Recipient Services (800) 362-3002 (608) 221-5720

Correspondents assist recipients, or persons calling on behalf of recipients, with questions about the following:

Available 7:30 a.m. - 5:00 p.m. (M-F)

• Recipient eligibility. • General Medicaid information.

• Finding Medicaid-certified providers. • Resolving recipient concerns.


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PHC 1050

Table of Contents

Preface .......................................................................................................................... 3

General Information ....................................................................................................... 5

Core and Other Functions of Hospice .......................................................................... 5Core Functions ..................................................................................................... 5Other Functions ................................................................................................... 5

Provider Certification ................................................................................................. 6Scope of Service ....................................................................................................... 6Medicaid Provider Responsibilities .............................................................................. 6Hospice Responsibilities ............................................................................................. 7Recipient Eligibility .................................................................................................... 7Hospice Enrollment ................................................................................................... 7Hospice Recipient Requirements ................................................................................. 8

Designated Primary Provider ................................................................................. 8Discontinuation or Transfer ................................................................................... 8Recipients Residing in Nursing Homes ................................................................... 8

Copayment ............................................................................................................... 9

Covered Services.......................................................................................................... 11

Hospice Care Service Categories ............................................................................... 11Hospice Care Services and Limitations ...................................................................... 11

Routine Care ...................................................................................................... 11Continuous Care ................................................................................................ 11Inpatient Respite Care ........................................................................................ 11

Limitations Applicable to Inpatient Respite Care............................................... 11General Inpatient Care ........................................................................................ 12

Limitations Applicable to Inpatient Respite and General Inpatient Care .............. 12Nursing Home Room and Board ............................................................................... 12

Limitations Applicable to Nursing Home Room and Board ..................................... 12Physician Services ................................................................................................... 13Durable Medical Equipment/Personal Care Services .................................................... 13Reimbursement Not Available .................................................................................. 13

Required Documentation .............................................................................................. 15

Physician Certification/Recertification of Terminal Illness ............................................ 15Recipient Election of Medicaid Hospice Benefit ........................................................... 15Notification of Medicaid Hospice Benefit Election ........................................................ 16Plan of Care ............................................................................................................ 16Ordering Forms ...................................................................................................... 17Form Retention and Submission ............................................................................... 17


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Prior Authorization ....................................................................................................... 19

Prior Authorization for Personal Care Services ........................................................... 19

Claims Submission ....................................................................................................... 21

Coordination of Benefits .......................................................................................... 21837 Health Care Claim: Institutional ......................................................................... 21UB-92 .................................................................................................................... 21Billed Amounts ....................................................................................................... 22Billing Increments ................................................................................................... 22Diagnosis Codes ..................................................................................................... 22Revenue Codes ....................................................................................................... 22Fee Schedule .......................................................................................................... 22

Reimbursement ........................................................................................................... 23

Nursing Home Room and Board ............................................................................... 23Paper Adjustment Requests ................................................................................ 23

Patient Liability ....................................................................................................... 24Hospice Cap on Overall Reimbursement.................................................................... 24

Appendix .................................................................................................................... 25

1. UB-92 (CMS 1450) Claim Form Instructions for Hospice Services............................... 272. UB-92 Claim Form Sample ..................................................................................... 353. Physician Certification/Recertification of Terminal Illness (for photocopying) ............... 374. Notification of Medicaid Hospice Benefit Election (for photocopying) .......................... 395. Recipient Election of Medicaid Hospice Benefit (for photocopying).............................. 436. Hospice Benefit Revocation (Non-recertification)/Voluntary Discharge (for

photocopying) ....................................................................................................... 457. Allowable Revenue Codes for Hospice Care.............................................................. 478. Rounding Guidelines for Continuous Care ................................................................ 499. Services Provided Outside the Hospice Benefit .......................................................... 5110. Sample Adjustment/Reconsideration Request for Retroactive Nursing Home Rate

Adjustment ........................................................................................................... 53

Index .......................................................................................................................... 55


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Hospice Services Handbook ! March 2006 3

PPrefaceThis Hospice Services Handbook is issued to allMedicaid-certified hospice providers. The information inthis handbook applies to Medicaid and BadgerCare.

Medicaid is a joint federal and state program establishedin 1965 under Title XIX of the federal Social Security Act.Wisconsin Medicaid is also known as the MedicalAssistance Program, WMAP, MA, Title XIX, and T19.

BadgerCare extends Medicaid coverage through aMedicaid expansion under Titles XIX and XXI. The goalof BadgerCare is to fill the gap between Medicaid andprivate insurance without supplanting or crowding outprivate insurance. BadgerCare recipients receive thesame benefits as Medicaid recipients, and their healthcare is administered through the same delivery system.

Wisconsin Medicaid and BadgerCare are administered bythe Department of Health and Family Services (DHFS).Within the DHFS, the Division of Health Care Financingis directly responsible for managing Wisconsin Medicaidand BadgerCare.

Unless otherwise specified, all information contained inthis and other Medicaid publications pertains to servicesprovided to recipients who receive care on a fee-for-service basis. Refer to the Managed Care section of theAll-Provider Handbook for information about state-contracted managed care organizations.

Handbook OrganizationThis Hospice Services Handbook consists of thefollowing chapters:

• General Information.• Covered Services.• Required Documentation.• Prior Authorization.• Claims Submission.• Reimbursement.

All-Provider HandbookAll Medicaid-certified providers receive a copy of the All-Provider Handbook, which includes the followingsections:

• Certification and Ongoing Responsibilities.• Claims Information.• Coordination of Benefits.• Covered and Noncovered Services.• Informational Resources.• Managed Care.• Prior Authorization.• Recipient Eligibility.

Providers are required to refer to the All-ProviderHandbook for information about these topics.


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4 Wisconsin Medicaid and BadgerCare ! dhfs.wisconsin.gov/medicaid/ ! March 2006

Wisconsin Medicaid andBadgerCare Web SitesPublications (including provider handbooks andWisconsin Medicaid and BadgerCare Updates),maximum allowable fee schedules, telephone numbers,addresses, and more information are available on thefollowing Web sites:

• dhfs.wisconsin.gov/medicaid/.• dhfs.wisconsin.gov/badgercare/.

PublicationsMedicaid publications apply to both Wisconsin Medicaidand BadgerCare. Publications interpret and implement thelaws and regulations that provide the framework forWisconsin Medicaid and BadgerCare. Medicaidpublications provide necessary information about programrequirements.

Legal FrameworkThe following laws and regulations provide the legalframework for Wisconsin Medicaid and BadgerCare:

• Federal Law and Regulation:✓ Law — United States Social Security Act;

Title XIX (42 US Code ss. 1396 andfollowing) and Title XXI.

✓ Regulation — Title 42 CFR Parts 430-498 andParts 1000-1008 (Public Health).

• Wisconsin Law and Regulation:✓ Law — Wisconsin Statutes: 49.43-49.499 and

49.665.✓ Regulation — Wisconsin Administrative Code,

Chapters HFS 101-109.

Laws and regulations may be amended or added at anytime. Program requirements may not be construed tosupersede the provisions of these laws and regulations.


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GHospice care provides services for people whoare terminally ill and for their family members.Hospice care is designed to do the following:

• Affirm life and neither hasten norpostpone death.

• Emphasize living one’s remaining days asfully as possible.

• Provide grief support to the survivingfamily.

• Provide patient-directed care for theterminally ill recipient and family.

• Provide relief from the physical andemotional pain that often accompanies aterminal illness.

HFS 107.31(2)(a), Wis. Admin. Code, defineshospice services as the following:

Those services provided to an eligiblerecipient by a provider certified under s.HFS 105.50 which are necessary for thepalliation and management of terminalillness and related conditions. Theseservices include supportive care providedto the family and other individuals caringfor the terminally ill recipient.

Core and Other Functionsof HospiceHospice services can either be provideddirectly by the hospice or by an organizationunder contract with the hospice. The followingare descriptions of core functions (thoseservices provided directly by the hospice) andother functions (those specialty services thatmay be provided by an organization undercontract with the hospice). The hospice isrequired to maintain professional, financial, andadministrative responsibility for both core andother functions.

Core FunctionsCore functions required under HFS107.31(2)(c), Wis. Admin. Code, must beprovided directly by the hospice unless anemergency or extraordinary circumstanceexists.

The following services are core functions thatmust be provided directly by hospiceemployees unless the recipient is receivingshort-term institutional care:

• Administrative and supervisory physicianservices.

• Counseling services, including, but notlimited to, bereavement counseling, dietarycounseling, and spiritual counseling.Counseling services must be available tothe terminally ill and the family membersor other persons caring for the individual athome.

• Medical social services provided by asocial worker under the direction of aphysician. The social worker is required tohave at least a Bachelor’s degree in socialwork from a college or universityaccredited by the Council of Social WorkEducation.

• Nursing care by, or under the supervisionof, a registered nurse, including homehealth aide services.

• Volunteer services.

Other FunctionsOther functions related to the terminal illnessare defined as those supplemental servicesrequired under HFS 107.31(2)(d), Wis. Admin.Code, for which a hospice may contract tomeet unusual staffing needs when it is notpractical to hire additional staff or to obtain

General Information

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Core functionsrequired underHFS 107.31(2)(c),Wis. Admin. Code,must be provideddirectly by thehospice unless anemergency orextraordinarycircumstanceexists.


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physician specialty services. Other functionsinclude the following:

• Physical therapy (PT).• Occupational therapy (OT).• Speech and language pathology (SLP).• Durable medical equipment, disposable

medical supplies, and personal care itemsrelated to palliation or management of therecipient’s terminal illness, provided by thehospice for use in the recipient’s homewhile under hospice care, as part of thewritten plan of care (POC).

• Drugs that are used primarily for the reliefof pain and symptom control and related tothe individual’s terminal illness.

• Short-term inpatient care provided in ahospital or skilled nursing facility (SNF) forpain control, acute symptom management,and respite purposes.

Note: Physical therapy, OT, and SLP servicesmay be provided for purposes ofsymptom control or to enable therecipient to maintain activities of dailyliving and basic functional skills.

Contracts with other organizations mustinclude identification of services to be provided,the qualifications of the contractor’s personnel,the role and responsibility of each party, and astipulation that all services provided be inaccordance with applicable state and federalstatutes, rules and regulations, and conform toaccepted standards of professional practice.Contracted functions are paid for by thehospice.

Provider CertificationHospice providers are required, under HFS105.50, Wis. Admin. Code, to be enrolled inMedicare as a hospice under 42 CFR s.418.50-418.100.

The attending physician is required to beindividually certified as a physician in order tosubmit claims to Wisconsin Medicaid.Hospices that wish to submit claims for more

than one physician may obtain a physiciangroup billing number, but each attendingphysician is required to be individuallyMedicaid certified.

Scope of ServiceSection 49.46(2)(b)10, Wis. Stats., and HFS101.03(75m) and 107.31(2)(a), Wis. Admin.Code, provide the legal framework for theprogram requirements in this handbook.

Medicaid ProviderResponsibilitiesWisconsin Medicaid-certified providers haveseveral responsibilities that include, but arenot limited to, the following:

• Providing the same level and quality ofcare to Medicaid recipients as private-pay patients.

• Submitting claims only for services thatwere actually provided.

• Complying with all state and federallaws related to Wisconsin Medicaid.

• Obtaining prior authorization for certainservices, when applicable.

• Notifying recipients in advance if aservice is not Medicaid covered.

• Maintaining accurate medical and billingrecords.

• Allowing recipient access to his or herrecords.

• Monitoring contracted staff.• Accepting Medicaid reimbursement as

payment in full for covered services.• Keeping information current.• Notifying Wisconsin Medicaid of

changes in ownership.• Responding to Medicaid recertification

notifications.• Safeguarding recipient confidentiality.• Verifying recipient eligibility, including

other health insurance sources and state-contracted managed care organizationcoverage.

• Keeping up-to-date with changes inprogram requirements as announced inMedicaid publications.

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Hospices that wishto submit claimsfor more than onephysician mayobtain a physiciangroup billingnumber, but eachattending physicianis required to beindividuallyMedicaid certified.


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It is essential that providers refer to the All-Provider Handbook for more information onthese and other topics.

Hospice ResponsibilitiesEach hospice is required to have aninterdisciplinary team or group to provide orsupervise care and services. This group ismade up of at least a physician, a registerednurse, a medical social worker, and a pastoralcounselor or other counselor — all of whomare employees of the hospice.

Refer to the Certification and OngoingResponsibilities section of the All-ProviderHandbook for detailed information aboutspecific responsibilities for Medicaid-certifiedproviders, fair treatment of the recipient,maintenance of records, recipient requests fornoncovered services, services rendered to arecipient during periods of retroactive eligibility,grounds for provider sanctions, and additionalstate and federal requirements.

Recipient EligibilityMedicaid providers should always verify arecipient’s eligibility before providingservices, both to determine eligibility for thecurrent date and to discover any limitationsto the recipient’s coverage.

Eligibility information for specific recipientsis available from the Medicaid EligibilityVerification System (EVS). The EVS is usedby providers to verify recipient eligibility,including whether the recipient has aMedicaid hospice as the designated primaryprovider, is enrolled in a Medicaid HMO orSSI MCO, has other health insurance, or isin a limited benefit category. Providers canaccess the EVS through the followingmethods:

• 270/271 Health Care Eligibility BenefitInquiry/Response transactions.

• Automated Voice Response system.• Commercial eligibility verification

vendors (accessed through software,

magnetic stripe card readers, and theInternet).

• Provider Services at (800) 362-3002 or(608) 221-5720.

Refer to the Recipient Eligibility section ofthe All-Provider Handbook for moreinformation about recipient eligibility.

Hospice EnrollmentA Medicaid recipient is eligible for hospiceservices if the following conditions are met:

1. A physician certifies that the recipienthas a terminal illness that reduces hisor her life expectancy to six months orless if the terminal illness runs itsnormal course. The physicianaccomplishes this by completing aPhysician Certification/Recertification ofTerminal Illness form, HCF 1011, andretaining a copy in the recipient’s records.Refer to the Required Documentationchapter of this handbook for moreinformation and to Appendix 3 of thishandbook for the Physician Certification/Recertification of Terminal Illness form.

2. The recipient elects the hospice benefitand waives regular Medicaid benefitsfor care and/or treatment of theterminal illness or related condition.The recipient indicates this election bycompleting and signing the RecipientElection of Medicaid Hospice Benefitform, HCF 1009. Refer to the RequiredDocumentation chapter of this handbookfor more information and to Appendix 5 ofthis handbook for the Recipient Election ofMedicaid Hospice Benefit form.

3. The hospice notifies WisconsinMedicaid of the recipient’s hospiceelection by completing and sending inthe Notification of Medicaid HospiceBenefit Election form, HCF 1008. Referto the Required Documentation chapter ofthis handbook for more information and toAppendix 4 of this handbook for the

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Medicaid providersshould alwaysverify a recipient’seligibility beforeproviding services,both to determineeligibility for thecurrent date and todiscover anylimitations to therecipient’scoverage.


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Notification of Medicaid Hospice BenefitElection form.

4. The attending physician and theinterdisciplinary team establish awritten POC before hospice servicesare provided. Refer to the RequiredDocumentation chapter of this handbookfor more information.

Hospice RecipientRequirements

Designated Primary ProviderWhen Wisconsin Medicaid receives theNotification of Medicaid Hospice BenefitElection form, the recipient is required toreceive all services related to the terminalillness from the hospice and attending physicianselected, regardless of whether or not thatphysician is employed by the hospice. Therecipient remains eligible for some Medicaidbenefits to treat conditions not directly relatedto the terminal illness, such as diabetes or otherillnesses.

Discontinuation or TransferA recipient may discontinue the election ofhospice care at any time. To discontinuereceiving hospice services, a recipient isrequired to complete and sign the HospiceBenefit Revocation (Non-recertification)/Voluntary Discharge form, HCF 1010. Referto Appendix 6 of this handbook for a copy ofthis form. The hospice is required to keep thisform in the recipient’s records. The hospice isrequired to complete and send the Notificationof Medicaid Hospice Benefit Election form tonotify Wisconsin Medicaid of thediscontinuation of hospice services. Thetermination date for hospice services is thedate the recipient signed the Hospice BenefitRevocation (Non-recertification)/VoluntaryDischarge form.

According to HFS 131.44(3), Wis. Admin.Code, the hospice may be required to givewritten notice to the recipient, or authorized

person acting on behalf of the recipient, and hisor her attending physician at least 14 days priorto the recipient’s voluntary or involuntarydischarge. The recipient may agree to waivethis waiting period by indicating so on theHospice Benefit Revocation (Non-recertification)/Voluntary Discharge form.

Upon discontinuation of hospice care, therecipient resumes regular Medicaid coverage,so long as the recipient remains eligible forWisconsin Medicaid. A recipient may re-electto receive hospice coverage at any time,provided he or she remains eligible for thehospice benefit.

A recipient may change the hospice fromwhich he or she receives care. The change ofthe designated hospice is not considered adiscontinuation of the election. To change thedesignation of a hospice program, a recipientmust file a statement with both the hospicefrom which he or she has received care andthe newly designated hospice that includes thefollowing:

• The name of the hospice from which therecipient has been receiving care.

• The name of the hospice from which he orshe plans to receive care.

• The date the change will be effective.

If a hospice recipient chooses to discontinue ortransfer hospice services, the hospice isrequired to notify Wisconsin Medicaid withinfive working days of the date of discontinuationor transfer at the following address:

Wisconsin MedicaidRecipient ServicesPO Box 6678Madison WI 53716-0678

Recipients Residing in NursingHomesWhen a resident of a Medicaid-certified SNFelects to receive hospice care services and thehospice has a contract with that nursing home,the provider is required to complete Section II

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A recipient maydiscontinue theelection of hospicecare at any time.To discontinuereceiving hospiceservices, arecipient isrequired tocomplete and signthe Hospice BenefitRevocation (Non-recertification)/VoluntaryDischarge form,HCF 1010.


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of the Notification of Medicaid HospiceBenefit Election form and submit it toWisconsin Medicaid. If a recipient enters anursing home after admission to a hospice, theprovider is required to complete Section III ofthe Notification of Medicaid Hospice BenefitElection form and submit it to WisconsinMedicaid.

CopaymentProviders are prohibited from collectingcopayment for hospice services. Services thatare provided outside the hospice benefit, whichare not directly related to management orpalliation of the recipient’s terminal illness, maybe subject to copayment.

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CCovered ServicesHospice Care ServiceCategoriesA hospice is reimbursed for services itprovides to a recipient based on the followingcategories of hospice care:

• Routine care, with a per diem rate for lessthan eight hours of care per day.

• Continuous care, with an hourly rate foreight to 24 hours of care per day.

• Inpatient respite care in a hospital orskilled nursing facility (SNF) meeting SNFstaffing, hourly, and environmentalrequirements.

• General inpatient care in a hospital orSNF.

Hospice Care Servicesand LimitationsHospice services covered by WisconsinMedicaid are billed under the categories ofcare listed previously. Refer to the ClaimsSubmission chapter of this handbook for moreinformation and Appendix 7 of this handbookfor allowable revenue codes.

Wisconsin Medicaid will reimburse only one ofthe four categories of hospice care on a singledate of service (DOS).

Routine CareRoutine care is hospice care that is needed ona regular, part-time basis and is provided in therecipient’s place of residence (e.g., home ornursing facility).

Routine care may be reimbursed for each daythat the recipient is receiving hospice care andat home or permanently residing in a nursingfacility. Wisconsin Medicaid will reimburse ahospice for routine care if less than eight hoursof care is provided in a day.

Continuous CareWisconsin Medicaid will reimburse a hospicefor continuous care if a minimum of eighthours of care is provided on a DOS. A DOSbegins and ends at midnight. The recipient maybe at home or permanently residing in anursing facility.

Continuous care is nursing care provided byeither a registered nurse (RN) or licensedpractical nurse (LPN). An RN or LPN isrequired to provide care for more than half ofthe minimum eight-hour period within a 24-hour period. The time billed does not need tobe continuous (e.g., four hours in the morningand four hours in the afternoon). Homemakerand aide services may be provided tosupplement the nursing care.

Inpatient Respite CareInpatient respite care is short-term inpatientcare provided to the hospice recipient onlywhen necessary to relieve the family membersor others caring for the recipient at home.

For each day inpatient respite care is provided,the hospice is required to submit claims toWisconsin Medicaid for services using theinpatient respite care revenue code. Thehospice is responsible for paying the hospital orSNF that provided the care.

Inpatient care for respite purposes must beprovided by a Medicaid-certified hospital orSNF that meets the additional certificationrequirements noted in HFS 132, Wis. Admin.Code, regarding staffing, patient areas, and 24-hour nursing service for SNFs.

Limitations Applicable to InpatientRespite CareAn inpatient stay for respite care must notexceed five consecutive days per instance,including the date of admission but not countingthe date of discharge.

Covered Services

WisconsinMedicaid willreimburse only oneof the fourcategories ofhospice care on asingle date ofservice (DOS).


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WInpatient care exceeding five consecutive daysmust be medically necessary for pain controland symptom management and must be billedas general inpatient care.

General Inpatient CareGeneral inpatient care is short-term inpatientcare necessary for pain control and symptommanagement.

For each day general inpatient care is provided,the hospice is required to submit claims toWisconsin Medicaid for services using thegeneral inpatient care revenue code. Thehospice is responsible for paying the hospital orSNF that provided the care.

General inpatient care must be provided by aMedicaid-certified hospital, an SNF certified byWisconsin Medicaid, or a hospice certifiedunder 42 CFR Part 418 meeting conditionsspecified under 42 CFR s. 418.98.

Limitations Applicable to InpatientRespite and General Inpatient CareFor each hospice, the total number of inpatientdays (both for general inpatient care andinpatient respite care) must not exceed 20percent of the aggregate total number of daysof hospice care provided to all Medicaidrecipients enrolled in the hospice during thesame period, beginning with services renderedNovember 1 of each year and ending October31 of the next year. This limitation is appliedonce each year, at the end of the hospice capperiod. Inpatient days for persons withAcquired Immune Deficiency Syndrome(AIDS) diagnoses are not included in theselimitations.

If the aggregate number of inpatient days doesexceed 20 percent of the aggregate totalnumber of days of hospice care, the hospice isrequired to reimburse Wisconsin Medicaid forthe amount of reimbursement for days over the20 percent cap. Wisconsin Medicaid will notifythe hospice of the amount to be refunded.

For the date of discharge from an inpatientunit, the appropriate routine or continuous careprocedure code must be billed rather than aninpatient code, unless the recipient dies as aninpatient. When the recipient is discharged asdeceased, the general or respite inpatient careprocedure code must be billed for thedischarge date.

Nursing Home Room andBoardWhen a resident of a Medicaid-certified SNFelects to receive hospice care services, thehospice must contract with that facility toprovide the recipient’s room and board andthe hospice assumes responsibility for themanagement of the individual’s hospice care.

Room and board includes assistance inactivities of daily living and personal care,socializing activities, administration ofmedications, maintaining cleanliness of therecipient’s room, and supervising and assistingin the use of durable medical equipment(DME) and prescribed therapies. In thissituation, Wisconsin Medicaid will reimbursethe hospice for room and board charges andthe hospice will pay the nursing facility.

Each day that room and board is provided mustbe billed using the room and board revenuecode. Routine and continuous care hospiceservices may be billed, as appropriate, on thesame DOS that nursing home room and boardis billed.

Wisconsin Medicaid will reimburse the hospice95 percent of the nursing home’s current SNFrate for each DOS on which room and board isprovided.

Limitations Applicable to NursingHome Room and BoardRoom and board for an SNF resident is notreimbursed for the same DOS as inpatientrespite or general inpatient care.

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When a resident ofa Medicaid-certifiedSNF elects toreceive hospicecare services, thehospice mustcontract with thatfacility to providethe recipient’sroom and boardand the hospiceassumesresponsibility forthe managementof the individual’shospice care.


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Physician ServicesReimbursable physician services are thoseface-to-face care services provided by therecipient’s attending physician that are relatedto his or her terminal illness. These servicesare not included in the hospice cap amount, butare billed separately by the attending physician.Wisconsin Medicaid will reimburse the lesserof the provider’s usual and customary chargefor the services provided or the maximumallowable fee established for each allowableprocedure.

The rates for the various types of hospice careand room and board include reimbursement forthe general supervisory functions of attendingphysicians who are employed by, or undercontract with, the hospice. Services such asparticipation in the establishment of plans ofcare (POC), supervision of care and services,review or updating of POC, or establishmentof governing policies are not separatelyreimbursed since these costs are included inthe hospice rates.

Services provided by a referred physician arereimbursable only when deemed medicallynecessary by the attending physician and therecipient is referred by the attending physician.

Durable MedicalEquipment/PersonalCare ServicesIn the limited situations where DME, oxygen-related services, or personal care services areprovided to a hospice recipient but are notreimbursable under the hospice benefitbecause they are not directly related to thecare of the terminal illness, providers of theseservices are required to follow Medicaidrequirements for prior authorization (PA) andclaims submission. Refer to the PriorAuthorization chapter of this handbook forinformation on PA for personal care services.

Reimbursement NotAvailableWisconsin Medicaid may deny or recouppayment for covered services that fail to meetprogram requirements. Medicaidreimbursement is also not available fornoncovered services.

Refer to the Covered and NoncoveredServices section of the All-Provider Handbookfor more information about services that do notmeet program requirements, noncoveredservices, and situations when it is permissibleto collect payment from recipients fornoncovered services.

Hospice providers may not receive Medicaidreimbursement for the following:

• Administrative and supervisory physicianservices that are included in the hospicedaily rate.

• Physician services that are not covered forall Medicaid recipients.

• Services related to the terminal illness thatare provided by providers other than thehospice, its contractees, or the attendingphysician.

• Services that are curative rather thanpalliative.

Refer to Appendix 9 of this handbook forinformation about services provided outside thehospice benefit.

Covered Services

Services such asparticipation in theestablishment ofplans of care(POC), supervisionof care andservices, review orupdating of POC, orestablishment ofgoverning policiesare not separatelyreimbursed sincethese costs areincluded in thehospice rates.


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The documentation outlined in this chapter isrequired for all Medicaid recipients receivingthe hospice benefit. With the exception of theNotification of Medicaid Hospice BenefitElection form, HCF 1008, providers may usethe forms in this handbook or substitute theirown forms, as long as the provider’s formcontains all of the same information as theMedicaid form.

Note: Not all forms discussed in this chaptershould be sent to Wisconsin Medicaid;the following forms should be kept in therecipient’s record:• Physician Certification/

Recertification of Terminal Illness,HCF 1011.

• Recipient Election of MedicaidHospice Benefit, HCF 1009.

Physician Certification/Recertification ofTerminal IllnessThe recipient must have written certification bythe hospice medical director, the physicianmember of the interdisciplinary team, or therecipient’s attending physician stating that therecipient has a terminal illness that reduces lifeexpectancy to six months or less if the terminalillness runs its normal course. An inter-disciplinary group is defined as a group ofpersons designated by a hospice to provide orsupervise care and services made up of atleast a physician, a registered nurse, a medicalsocial worker and a pastoral counselor or othercounselor, all of whom are employees of thehospice.

The physician(s) is required to sign a PhysicianCertification/Recertification of Terminal Illnessform and the hospice is required to keep arecord of it in the recipient’s record; the formin Appendix 3 of this handbook may be usedfor this purpose. If the recipient is not

deceased at the end of six months, thephysician is required to recertify that therecipient’s terminal illness reduces his or herlife expectancy to six months or less.

If a recipient discontinues hospice care andlater wishes to have hospice care reinstated,the attending physician must recertify that therecipient has a terminal illness that reduces hisor her life expectancy to six months or less.The recipient will then be recertified forhospice care for a full six months. Refer toAppendix 3 of this handbook for a copy of thePhysician Certification/Recertification ofTerminal Illness form.

If a verbal certification is obtained within twocalendar days after the initial six-month periodof care begins, the hospice has up to eightcalendar days after the six-month periodbegins to obtain a written physiciancertification of a recipient’s terminal illness. Ifthe physician’s written certification is notobtained within eight calendar days, onlyservices provided on and after the signaturedate of the physician’s certification arereimbursed.

The hospice is required to keep the PhysicianCertification/Recertification of Terminal Illnessform in the recipient’s record and should notsend it to Wisconsin Medicaid.

Recipient Election ofMedicaid Hospice BenefitA Recipient Election of Medicaid HospiceBenefit form must be completed and filed withthe hospice for a Medicaid recipient who hasbeen certified as terminally ill and who electsto receive hospice care. The election datedesignates the first date of service for whichhospice care can be reimbursed by WisconsinMedicaid. A recipient who signs an electionstatement elects hospice care benefits andwaives regular Medicaid benefits, except for

RRequired Documentation

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ocumentation

TThe recipient musthave writtencertification by thehospice medicaldirector, thephysician memberof theinterdisciplinaryteam, or therecipient’sattending physicianstating that therecipient has aterminal illness thatreduces lifeexpectancy to sixmonths or less ifthe terminal illnessruns its normalcourse.


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the services provided by an attendingphysician. An attending physician is defined asa physician who is a doctor of medicine orosteopathy certified under HFS 105.05, Wis.Admin. Code, and identified by the recipient ashaving the most significant role in thedetermination and delivery of his or hermedical care at the time the recipient elects toreceive hospice care.

The recipient may discontinue the election ofhospice care at any time and thereby have allMedicaid benefits reinstated. A recipient maychoose to reinstate hospice care services afterthey have discontinued these services. In theevent of reinstatement, the documentationrequirements of hospice apply.

The hospice is required to obtain a signedRecipient Election of Medicaid HospiceBenefit form, or its equivalent, prior toproviding hospice services to the recipient.Refer to Appendix 5 of this handbook for theRecipient Election of Medicaid HospiceBenefit form for photocopying.

Notification of MedicaidHospice Benefit ElectionAfter a Medicaid recipient elects the hospicebenefit, the hospice is required to notifyWisconsin Medicaid of the election within 30calendar days by using the Notification ofMedicaid Hospice Benefit Election form. Theuse of this form is mandatory; substitute formswill not be accepted by Wisconsin Medicaid.

For dual eligibles who elect hospice benefitsunder Medicare, the hospice is required tosubmit a copy of the Notification of MedicaidHospice Benefit Election form to bothWisconsin Medicaid and Medicare.

The hospice is required to indicate theattending physician’s name and Medicaidprovider number on the election form. Thisallows Wisconsin Medicaid to reimburse claimsfor the attending physician.

If the recipient electing hospice care iscurrently, or becomes, a resident of a skillednursing facility, the hospice is required to notifyWisconsin Medicaid of the nursing homeresidency by completing Section II or III on theNotification of Medicaid Hospice BenefitElection form and submitting it to WisconsinMedicaid. Claims submitted for room andboard will be denied if Wisconsin Medicaid hasnot received notice of the recipient’s nursinghome residence. The nursing home’s Medicaidprovider number and the recipient’s Medicaididentification number must be indicated. Referto Appendix 4 of this handbook for theNotification of Medicaid Hospice BenefitElection form that all hospice providers arerequired to use.

If a recipient is enrolled in a Medicaid HMO,the hospice should contact the recipient’sHMO for its hospice procedures. Hospicesshould not submit the Notification of MedicaidHospice Benefit Election form for recipientsenrolled in a Medicaid HMO.

Plan of CareA written plan of care (POC) must beestablished for recipients who elect to receivehospice services before hospice care isprovided. The POC should be kept in therecipient’s record and should not be sent toWisconsin Medicaid.

The attending physician, the medical director orphysician designee, and the interdisciplinaryteam are required to establish the POC. ThePOC must include:

• An assessment of the needs of therecipient.

• The identification of services to beprovided, including management ofdiscomfort and symptom relief.

• A description of the scope and frequencyof services to the recipient and therecipient’s family.

• A schedule for periodic review (at leastevery two weeks) and updating of the

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After a Medicaidrecipient elects thehospice benefit, thehospice is requiredto notify WisconsinMedicaid of theelection within 30calendar days byusing theNotification ofMedicaid HospiceBenefit Electionform.


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HHospice enrollmentrecords must bekept with therecipient’s recordin accordance withHFS 106.02(9),Wis. Admin. Code.

POC (as needed), evidenced by thephysician’s signature and date.

Ordering FormsMedicaid hospice forms may be downloadedfrom the Medicaid Web site.

Copies of these forms may also be obtained bywriting to the following address:

Wisconsin MedicaidForm Reorder6406 Bridge RdMadison WI 53784-0003

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ocumentation

Form Retention andSubmissionHospice enrollment records must be kept withthe recipient’s record in accordance with HFS106.02(9), Wis. Admin. Code.

Upon enrollment or a change of enrollment,the Notification of Medicaid Hospice BenefitElection form must be sent to WisconsinMedicaid at the following address within 30calendar days of election:

Wisconsin MedicaidRecipient ServicesPO Box 6678Madison WI 53716-0678


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HPPrior Authorization

Hospice services (core or other functions) donot require prior authorization (PA). Medicaid-covered services that would otherwise requirePA do not require PA when billed by theattending physician for a hospice recipient.

Providers of other Medicaid-covered servicesshould follow the program requirementsoutlined in their service-specific publications.

Prior Authorization forPersonal Care ServicesRecipients receiving personal care throughWisconsin Medicaid who elect the hospicebenefit may be eligible to continue receivingpersonal care services from the personal careagency if those services are not directly relatedto the terminal illness.

If this criterion is met, the agency providingpersonal care services will have alreadyreceived PA for the recipient. The personalcare agency is required to submit a Prior

Authorization Amendment Request, HCF11042, and attach a copy of the hospice plan ofcare (POC) that identifies the need forcontinued personal care services as well as thespecific services provided directly by thehospice. The POC must also indicate any aideservices to be provided by the hospice. Thismust be sent within seven calendar days of therecipient’s election of hospice care. Thecompletion instructions and Prior AuthorizationAmendment Request form are located in thePrior Authorization section of the All-ProviderHandbook for photocopying and may also bedownloaded and printed from the MedicaidWeb site.

When the personal care PA needs to berenewed, a current hospice POC must beincluded. Renewal of PA for personal careservices may be granted up to, but notexceeding, the current level of service.Additional personal care needs resulting fromthe terminal illness are the responsibility of thehospice.

Prior Authorization

Hospice services(core or otherfunctions) do notrequire priorauthorization (PA).Medicaid-coveredservices that wouldotherwise requirePA do not requirePA when billed bythe attendingphysician for ahospice recipient.


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Claims SubmissionTo receive reimbursement, claims andadjustment requests must be received byWisconsin Medicaid within 365 days of thedate of service (DOS). To receivereimbursement for services that are allowedby Medicare, claims and adjustment requestsfor coinsurance, copayment, and deductiblemust be received by Wisconsin Medicaidwithin 365 days of the DOS, or within 90days of the Medicare processing date,whichever is later.

For more information about exceptions to theclaims submission deadline, Medicaidremittance information, adjustment requests,and returning overpayments, refer to theClaims Information section of the All-Provider Handbook.

Coordination of BenefitsExcept for a few instances, WisconsinMedicaid is the payer of last resort for anyMedicaid-covered service. Therefore, theprovider is required to make a reasonableeffort to exhaust all existing other healthinsurance sources before submitting claimsto Wisconsin Medicaid or to state-contractedmanaged care organizations.

Because room and board are not covered byMedicare, claims for room and board for dualeligibles may be submitted directly toWisconsin Medicaid.

Refer to the Coordination of Benefits sectionof the All-Provider Handbook for moreinformation about services that require otherhealth insurance billing, exceptions, claimssubmission procedures for recipients withother health insurance, and the OtherCoverage Discrepancy Report, HCF 1159.

837 Health Care Claim:InstitutionalProviders are encouraged to submit claimselectronically since electronic claims submis-sion usually reduces claim errors. Claims forhospice services may be submitted using the837 Health Care Claim: Institutional (837I)transaction except when submitting claimsthat require additional documentation. Inthese situations, providers are required tosubmit paper claims.

Refer to the Informational Resources sectionof the All-Provider Handbook for moreinformation about electronic transactions.

UB-92Paper claims for hospice services must besubmitted using the UB-92 claim form (withthe exception of physician services).Wisconsin Medicaid denies claims forhospice services submitted on any paperclaim form other than the UB-92.

When Medicare is the primary payer, hospicesare required to follow the Medicareinstructions. All other UB-92 claim formssubmitted must follow the UB-92 claim forminstructions developed by Wisconsin Medicaid.

Wisconsin Medicaid does not provide theUB-92 claim form. The form may beobtained from any federal forms supplier.

The UB-92 completion instructions and asample claim form for hospice services can befound in Appendices 1 and 2 of this handbook.

Service limitations and billing instructions forphysician services are included in the PhysicianServices Handbook, which is available on theMedicaid Web site.

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Because room andboard are notcovered byMedicare, claimsfor room andboard for dualeligibles may besubmitted directlyto WisconsinMedicaid.


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Billed AmountsHospice providers submitting claims toWisconsin Medicaid for routine care,continuous care, inpatient respite care, orgeneral inpatient care are required to indicatetheir usual and customary charge for servicesprovided.

Hospice providers submitting claims for roomand board are required to indicate the nursinghome room and board rate. WisconsinMedicaid reimburses up to the Medicaid-established skilled nursing facility rate for thatnursing home.

The hospice or attending physician submittingclaims for physician services is required toindicate his or her usual and customary chargefor services provided.

Billing IncrementsWhen submitting claims for continuous careservices, hospice providers are required toindicate services in hour or half-hourincrements, rounded to the nearest half-hour.Refer to Appendix 8 of this handbook forrounding guidelines for these services.

When submitting claims for routine care,general inpatient care, inpatient respite care,and room and board, the service must beindicated as a quantity of “1” per DOS.

Diagnosis CodesAll diagnoses must be from the InternationalClassification of Diseases, Ninth Revision,Clinical Modifications (ICD-9-CM) codingstructure and must be allowed for the DOS.

Claims received without an allowable ICD-9-CM code are denied.

Hospice providers should note the followingdiagnosis code restrictions:

• Codes with an “E” prefix must not be usedas the primary or sole diagnosis on a claimsubmitted to Wisconsin Medicaid.

• Codes with an “M” prefix are notacceptable on a claim submitted toWisconsin Medicaid.

• Recipients with a diagnosis of AcquiredImmune Deficiency Syndrome (AIDS)/AIDS Related Condition (AIDS/ARC)must be identified with ICD-9-CM code042 for their services to be exempt fromthe hospice cap.

Revenue CodesRevenue codes are required on all claimssubmitted using the UB-92 or 837I. Claims oradjustment requests for hospice serviceswithout revenue codes are denied. Allowablerevenue codes and their descriptions forhospice services are included in Appendix 7 ofthis handbook.

Fee ScheduleThe maximum allowable fee is the maximumamount that Wisconsin Medicaid will pay aprovider for an allowable procedure code.Hospice providers may obtain a maximumallowable fee schedule that containsreimbursement rates from one of the followingsources:

• An electronic version on the MedicaidWeb site.

• A paper copy, which may be purchased bydoing either of the following:" Calling Provider Services at

(800) 947-9627 or (608) 221-9883 forthe cost of the fee schedule.

" Writing to the following address:

Wisconsin MedicaidProvider Maintenance6406 Bridge RdMadison WI 53784-0006

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Revenue codes arerequired on allclaims submittedusing the UB-92 or837I. Claims oradjustmentrequests forhospice serviceswithout revenuecodes are denied.


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RReimbursementWisconsin Medicaid reimburses the hospice forthe following services under five nationalrevenue codes:

• 0651: Hospice Services — Routine homecare.

• 0652: Hospice services — Continuoushome care.

• 0655: Hospice services — Inpatientrespite care.

• 0656: Hospice services — Generalinpatient care.

• 0169: Room and board — Other (forskilled nursing facility).

Hospice services are reimbursed at the perdiem or hourly amounts allowed by the federalCenters for Medicare and Medicaid Services(CMS). Wisconsin Medicaid reimburses thehospice directly; the hospice is then responsiblefor paying the nursing home or hospital. Referto the Covered Services chapter of thishandbook for more information about hospiceservices and nursing home room and board.Refer to Appendix 7 of this handbook for moreinformation about revenue codes.

Nursing Home Room andBoardFor hospice recipients who permanently residein a nursing home, Wisconsin Medicaidreimburses the hospice for nursing home roomand board at 95 percent of the nursing home’scurrent skilled nursing facility (SNF) rate,regardless of the recipient’s level of caredesignation.

Wisconsin Medicaid does not automaticallyadjust paid hospice claims for nursing homeroom and board if the nursing home’s rate ischanged retroactively. To receive a retroactiverate change, the hospice provider is required tosubmit an adjustment request for the affectedclaim.

The hospice is required to reimburse anyprovider with whom it has contracted forservice, including a facility providing inpatientcare under HFS 107.31(3)(d)3, Wis. Admin.Code.

Refer to the Claims Information section of theAll-Provider Handbook for more informationabout submitting adjustment requests.

Paper Adjustment RequestsThe completion instructions and Adjustment/Reconsideration Request form, HCF 13046,which are used to request a retroactive ratechange on paper, are located in the ClaimsInformation section of the All-ProviderHandbook for photocopying and may also bedownloaded and printed from the MedicaidWeb site. Refer to Appendix 10 of thishandbook for a sample Adjustment/Reconsideration Request for a retroactivenursing home rate adjustment. On Element 16of the Adjustment/Reconsideration Request,“Other” should be checked and the followingshould be written as a comment: “To obtainretroactive rate increase for nursing homeroom and board.” Reim

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WWisconsin Medicaiddoes notautomaticallyadjust paid hospiceclaims for nursinghome room andboard if the nursinghome’s rate ischangedretroactively.


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Patient LiabilityFor a hospice recipient residing in a nursinghome, the nursing home, hospice, andWisconsin Medicaid each play a role incollecting patient liability. Patient liability is theamount of an individual’s income that isavailable to apply on a monthly basis towardthe recipient’s cost of care.

The nursing home is responsible for:

• Collecting patient liability from theMedicaid recipient residing in their facility.

• Transferring the patient liability amount tothe recipient’s hospice.

• Billing the hospice its contracted amountfor room and board.

The hospice is responsible for:

• Paying the nursing home the contractedamount for room and board.

• Accepting as income the patient liabilityamount received from the nursing homeand reporting this amount on the claimsubmitted to Wisconsin Medicaid.

• Indicating its usual and customary amountfor nursing home room and board usingrevenue code 0169 for claims submitted toWisconsin Medicaid and submitting claimsto Wisconsin Medicaid only once percalendar month.

Wisconsin Medicaid is responsible for:

• Deducting the patient liability, as reportedto the state by the county, from the amountto be reimbursed to the hospice.

• Reimbursing the hospice 95 percent of thenursing home’s SNF rate minus thepatient’s liability.

Hospice Cap on OverallReimbursementEach year, CMS establishes a maximumamount for aggregate payments made to ahospice during a hospice cap period that runsfrom November 1 through October 31 of thefollowing year. The hospice cap period isdefined as the period of time during which thepayment for those hospice services countingtowards the cap will be counted, by date ofservice.

The aggregate payments do not includepayment for direct care by the attendingphysician or inpatient days for persons withAcquired Immune Deficiency Syndrome(AIDS). Payments made to hospices byWisconsin Medicaid in excess of the cap onoverall reimbursement will be recouped. TheDivision of Health Care Financing (DHCF)will notify the hospice of the overpayment andthe required repayment.

Payments are measured in terms of allpayments made to hospices on behalf of allMedicaid hospice beneficiaries receivingservices during the cap year, regardless of theyear in which a beneficiary is counted whendetermining the cap.

The computation and application of the capamount is made by the DHCF at the end of thecap period. The hospice will be responsible forreporting the number of Medicaid recipientselecting hospice care during the period to theDHCF. This must be done by November 30 ofeach year.

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Each year, CMSestablishes amaximum amountfor aggregatepayments made toa hospice during ahospice cap periodthat runs fromNovember 1through October 31of the followingyear.


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Appendix

Appendix 1UB-92 (CMS 1450) Claim Form Instructions for Hospice Services

Use the following claim form completion instructions, not the form locator descriptions printed on the claim form, toavoid denied claims or inaccurate claim payment. Complete all required form locators as appropriate. Do not includeattachments unless instructed to do so.

These instructions are for the completion of the UB-92 (CMS 1450) claim for Wisconsin Medicaid. For completebilling instructions, refer to the National UB-92 Uniform Billing Manual prepared by the National Uniform BillingCommittee (NUBC). The National UB-92 Uniform Billing Manual contains important coding information not availablein these instructions. Providers may purchase the National UB-92 Uniform Billing Manual by writing or calling:

American Hospital AssociationNational Uniform Billing Committee29th Fl1 N FranklinChicago IL 60606(312) 422-3390

For more information, go to the NUBC Web site at www.nubc.org/.

Wisconsin Medicaid recipients receive a Medicaid identification card upon being determined eligible for WisconsinMedicaid. Always verify a recipient’s eligibility before providing nonemergency services by using the Eligibility Verifi-cation System (EVS) to determine if there are any limitations on covered services and to obtain the correct spelling ofthe recipient’s name. Refer to the Informational Resources section of the All-Provider Handbook or the Medicaid Website for more information about the EVS.

Submit completed paper claims to the following address:

Wisconsin MedicaidClaims and Adjustments6406 Bridge RdMadison WI 53784-0002

Form Locator 1 — Provider Name, Address, and Telephone NumberEnter the name of the provider submitting the claim and the complete mailing address. The minimum requirement is theprovider’s name, street, city, state, and ZIP code. The name in Form Locator 1 should correspond with the provider numberin Form Locator 51.

Form Locator 2 — ERO Assigned Number (not required)

Form Locator 3 — Patient Control No. (not required)


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Form Locator 4 — Type of BillEnter the three-digit type of bill number. The first digit identifies the type of facility. The second digit classifies the type ofcare. Hospice providers should use bill types 81X (non-hospital-based hospice) and 82X (hospital-based hospice). The thirddigit (“X”) indicates the billing frequency, and providers should enter one of the following for “X”:

• 1 = Admit through discharge claim.• 2 = Interim — first claim.• 3 = Interim — continuing claim.• 4 = Interim — final claim.

Form Locator 5 — Fed. Tax No. (not required)

Form Locator 6 — Statement Covers Period (From - Through) (not required)

Form Locator 7 — Cov D. (not required)

Form Locator 8 — N-C D. (not required)

Form Locator 9 — C-I D. (not required)

Form Locator 10 — L-R D. (not required)

Form Locator 11 — Unlabeled Field (not required)

Form Locator 12 — Patient NameEnter the recipient’s last name, first name, and middle initial. Use the EVS to obtain the correct spelling of the recipient’sname. If the name or spelling of the name on the Medicaid identification card and the EVS do not match, use the spellingfrom the EVS.

Form Locator 13 — Patient Address (not required)

Form Locator 14 — Birthdate (not required)

Form Locator 15 — Sex (not required)

Form Locator 16 — MS (not required)

Form Locator 17 — Admission Date (not required)

Form Locator 18 — Admission Hr (not required)

Form Locator 19 — Admission Type (not required)

Form Locator 20 — Admission Src (not required)

Form Locator 21 — D Hr (not required)

Form Locator 22 — Stat (not required)

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Appendix

Form Locator 23 — Medical Record No.This is an optional field. Enter the number assigned to the patient’s medical/health record by the provider. This number willappear on the Remittance and Status Report and/or the 835 Health Care Claim Payment/Advice transaction.

Form Locators 24-30 — Condition Codes (required, if applicable)If appropriate, enter a code to identify conditions relating to this claim.


Form Locators 32-35 a-b — Occurrence Code and Date (required, if applicable)If appropriate, enter the code and associated date defining a significant event relating to this claim that may affect payerprocessing. Enter dates in MM/DD/YY format (e.g., January 1, 2004, would be 010104).

Form Locator 36 a-b — Occurrence Span Code (From - Through) (not required)

Form Locator 37 A-C — Internal Control Number/Document Control Number (not required)

Form Locator 38 — Responsible Party Name and Address (not required)

Form Locators 39-41 a-d — Value Code and Amount (required, if applicable)Wisconsin Medicaid uses the following value codes.

Form Locator 42 — Rev. Cd.Enter the national four-digit revenue code that identifies a specific accommodation, ancillary service, or billing calculation.Enter revenue code “0001” on the line with the sum of all the charges.

Form Locator 43 — DescriptionEnter the date of service (DOS) in MM/DD/YY format in Form Locator 43 or Form Locator 45.

When series billing (i.e., billing from two to four DOS on the same line), indicate the DOS in the following format:MM/DD/YY MM/DD MM/DD MM/DD. Indicate the dates in ascending order. Providers may enter up to four DOS foreach revenue code if:• All DOS are in the same calendar month.• All procedures performed are identical.• All procedures were performed by the same provider.• The number of units indicated in Form Locator 46 must be divisible by the number of DOS.

If it is necessary to indicate more than four DOS per revenue code, indicate the dates on the subsequent lines. On paperclaims, no more than 23 lines may be submitted on a single claim including the “Total Charges” line.

Form Locator 44 — HCPCS/Rates (not required)

Code Description

81 Medicare Part B Charges When Part A Exhausted. Enter the full amount of MedicarePart B charges when billing for services after Medicare Part A has been exhausted.

83 Medicare Part A Charges When Part A Exhausted. Enter the sum of the Medicarepaid amount, the coinsurance amount, and the deductible when billing for servicesafter Medicare Part A has been exhausted.



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Form Locator 45 — Serv. DateEnter the DOS in MM/DD/YY format in Form Locator 45 or Form Locator 43. Multiple DOS must be indicated in FormLocator 43.

Form Locator 46 — Serv. UnitsEnter the number of reimbursable accommodations days, ancillary units of service, or visits, where appropriate. Units aremeasured in days for revenue codes “0169,” “0651,” “0655,” and “0656,” and in hours for revenue code “0652.”

Form Locator 47 — Total ChargesEnter the usual and customary charge for each line item. Enter revenue code “0001” to report the sum of all charges inForm Locator 47.

Form Locator 48 — Non-covered Charges (not required)


Form Locator 50 A-C — PayerEnter all health insurance payers here. For example, enter “T19” for Wisconsin Medicaid and/or the name of privateinsurance. Enter “patient liability amount” to identify any patient liability.

Form Locator 51 A-C — Provider No.Enter the number assigned to the provider by the payer indicated in Form Locator 50 A-C. For Wisconsin Medicaid, enterthe eight-digit provider number. The provider number in Form Locator 51 should correspond with the name in Form Locator1.

Form Locator 52 A-C — Rel Info (not required)

Form Locator 53 A-C — Asg Ben (not required)

Form Locator 54 A-C & P — Prior Payments (required, if applicable)Enter the actual amount paid by commercial insurance. (If the dollar amount indicated in Form Locator 54 is greater thanzero, “OI-P” must be indicated in Form Locator 84.) If the commercial insurance denied the claim, enter “000.” Do notenter Medicare-paid amounts in this field, but attach a copy of the Medicare remittance information.

Form Locator 55 A-C & P — Est Amount Due (required, if applicable)Enter the dollar amount of any patient liability.



Form Locator 58 A-C — Insured’s Name (not required)

Form Locator 59 A-C — P. Rel (not required)

Form Locator 60 A-C — Cert. - SSN - HIC. - ID No.Enter the recipient’s 10-digit Medicaid identification number. Do not enter any other numbers or letters. Use the Medicaididentification card or EVS to obtain the correct identification number.



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Form Locator 61 A-C — Group Name (not required)

Form Locator 62 A-C — Insurance Group No. (not required)

Form Locator 63 A-C — Treatment Authorization Codes (not required)

Form Locator 64 A-C — ESC (not required)

Form Locator 65 A-C — Employer Name (not required)

Form Locator 66 A-C — Employer Location (not required)

Form Locator 67 — Prin. Diag Cd.Enter the full International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code (up tofive digits) describing the principal diagnosis (e.g., the condition established after study to be chiefly responsible for causingthe admission or other health care episode). Do not enter manifestation codes as the principal diagnosis; code the underlyingdisease first. The principal diagnosis may not include “E” codes.

Form Locators 68-75 — Other Diag. CodesEnter valid ICD-9-CM diagnosis codes corresponding to additional conditions that coexist at the time of admission, ordevelop subsequently, and that have an effect on the treatment received or the length of stay. Diagnoses that relate to anearlier episode and that have no bearing on this episode are to be excluded. Providers should prioritize diagnosis codes asrelevant to this claim.

Form Locator 76 — Adm. Diag. Cd. (not required)

Form Locator 77 — E-Code (not required)

Form Locator 78 — Race/Ethnicity (not required)

Form Locator 79 — P.C. (not required)

Form Locator 80 — Principal Procedure Code and Date (not required)

Form Locator 81 — Other Procedure Code and Date (not required)

Form Locator 82 a-b — Attending Phys. IDEnter the Universal Provider Identification Number or license number and name.

Form Locator 83 a-b — Other Phys. ID (not required)

Form Locator 84 a-d — Remarks (enter information when applicable)

Commercial Health Insurance Billing InformationCommercial health insurance coverage must be billed prior to billing Wisconsin Medicaid, unless the service does not requirecommercial health insurance billing as determined by Wisconsin Medicaid.



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If the recipient has dental (“DEN”) or has no commercial health insurance, do not indicate an other insurance (OI)explanation code in Form Locator 84.

When the recipient has Wausau Health Protection Plan (“HPP”), BlueCross & BlueShield (“BLU”), Wisconsin PhysiciansService (“WPS”), Medicare Supplement (“SUP”), TriCare (“CHA”), Vision only (“VIS”), a health maintenanceorganization (“HMO”), or some other (“OTH”) commercial insurance, and the service requires commercial healthinsurance billing according to the Coordination of Benefits section of the All-Provider Handbook, then one of the followingthree OI explanation codes must be indicated in Form Locator 84. The description is not required, nor is the policyholder,plan name, group number, etc.

Note: The provider may not use OI-D or OI-Y if the recipient is covered by a commercial HMO and the HMOdenied payment because an otherwise covered service was not rendered by a designated provider. Servicescovered by a commercial HMO are not reimbursable by Wisconsin Medicaid except for the copayment anddeductible amounts. Providers who receive a capitation payment from the commercial HMO may not submitclaims to Wisconsin Medicaid for services that are included in the capitation payment.

Medicare InformationUse Form Locator 84 for Medicare information. Submit claims to Medicare before billing Wisconsin Medicaid.

Do not indicate a Medicare disclaimer code when one or more of the following statements is true:

• Medicare never covers the procedure in any circumstance.• Wisconsin Medicaid indicates the recipient does not have any Medicare coverage including Medicare Cost (“MCC”) or

Medicare + Choice (“MPC”) for the service provided. For example, the service is covered by Medicare Part A, but therecipient does not have Medicare Part A.

• Wisconsin Medicaid indicates the provider is not Medicare certified.• Medicare has allowed the charges. In this case, attach the Explanation of Medicare Benefits or Medicare Remittance

Advice, but do not indicate on the claim form the amount Medicare paid.

Code DescriptionOI-P PAID in part or in full by commercial health insurance or commercial HMO. In Form Locator 54 of

this claim form, indicate the amount paid by commercial health insurance to the provider or to theinsured.

OI-D DENIED by commercial health insurance or commercial HMO following submission of a correctand complete claim, or payment was applied towards the coinsurance and deductible. Do not usethis code unless the claim was actually billed to the commercial health insurer.

OI-Y YES, the recipient has commercial health insurance or commercial HMO coverage, but it was notbilled for reasons including, but not limited to:" The recipient denied coverage or will not cooperate." The provider knows the service in question is not covered by the carrier." The recipient’s commercial health insurance failed to respond to initial and follow-up claims." Benefits are not assignable or cannot get assignment." Benefits are exhausted.



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Appendix

If none of the previous Medicare information is true, a Medicare disclaimer code is necessary. The following Medicaredisclaimer codes may be used when appropriate:

Code DescriptionM-5 Provider is not Medicare certified. This code may be used when providers are

identified in Wisconsin Medicaid files as being Medicare certified, but are billing for DOSbefore or after their Medicare certification effective dates. Use M-5 in the followinginstances:For Medicare Part A (all three criteria must be met):" The provider is identified in Wisconsin Medicaid files as certified for Medicare Part A,

but the provider was not certified for the date the service was provided." The recipient is eligible for Medicare Part A." The procedure provided is covered by Medicare Part A.For Medicare Part B (all three criteria must be met):" The provider is identified in Wisconsin Medicaid files as certified for Medicare Part B,

but the provider was not certified for the date the service was provided." The recipient is eligible for Medicare Part B." The procedure provided is covered by Medicare Part B.

M-7 Medicare disallowed or denied payment. This code applies when Medicare deniesthe claim for reasons related to policy (not billing errors), or the recipient's lifetimebenefit, spell of illness, or yearly allotment of available benefits is exhausted. Use M-7 inthe following instances:For Medicare Part A (all three criteria must be met):" The provider is identified in Wisconsin Medicaid files as certified for Medicare Part A." The recipient is eligible for Medicare Part A." The service is covered by Medicare Part A but is denied by Medicare Part A due to

frequency limitations, diagnosis restrictions, or the service is not payable due tobenefits being exhausted.

For Medicare Part B (all three criteria must be met):" The provider is identified in Wisconsin Medicaid files as certified for Medicare Part B." The recipient is eligible for Medicare Part B." The service is covered by Medicare Part B but is denied by Medicare Part B due to

frequency limitations, diagnosis restrictions, or the service is not payable due tobenefits being exhausted.

M-8 Noncovered Medicare service. This code may be used when Medicare was not billedbecause the service is not covered in this circumstance. Use M-8 in the followinginstances:For Medicare Part A (all three criteria must be met):" The provider is identified in Wisconsin Medicaid files as certified for Medicare Part A." The recipient is eligible for Medicare Part A." The service is usually covered by Medicare Part A but not in this circumstance (e.g.,

recipient's diagnosis).For Medicare Part B (all three criteria must be met):" The provider is identified in Wisconsin Medicaid files as certified for Medicare Part B." The recipient is eligible for Medicare Part B." The service is usually covered by Medicare Part B but not in this circumstance (e.g.,

recipient's diagnosis).



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Form Locator 85 — Provider RepresentativeThe provider or the authorized representative must sign in Form Locator 85.

Note: The signature may be a computer-printed or typed name and date or a signature stamp with the date.

Form Locator 86 — DateEnter the month, day, and year on which the claim is submitted to the payer. The date must be entered in MM/DD/YY orMM/DD/YYYY format.


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Appendix

Appendix 2UB-92 Claim Form Sample

4.0 XXX XX 4.0 XXX XX 4.0 XXX XX 4.0 XXX XX 4.0 XXX XX 4.0 XXX XX 4.0 XXX XX 1.0 XX XX

4.0 XXX XX 1.0 XX XX

XXXX XX

IM BILLING HOSPICE321 HOSPICE RDANYTOWN, WI 55555(555) 321-1234

811

RECIPIENT, IMA H.

0169 020104 0202 0203 0204 0205 0206 0207 0208 0209 0210 0211 0212 0213 0214 0215 0216 0217 0218 0219 0220 0221 0222 0223 0224

0225 0226 0227 0228 0229

0651 022504 0226 0227 0228 0229

0001 TOTAL CHARGES

45009 BLUE CROSS BC111T19 MEDICAID 87654321PATIENT LIABILITY

042 486 7070 4280N24680 I.M. Physician

030104Ima H. Provider

1234567890

OI-P

XXXX XX

XX XX


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Appendix

Appendix 3Physician Certification/Recertification of Terminal Illness

(for photocopying)

(A copy of the Physician Certification/Recertification of Terminal Illness formis located on the following page.)


for current policy

DEPARTMENT OF HEALTH AND FAMILY SERVICES STATE OF WISCONSIN Division of Health Care Financing HFS 107.31(2)(b), Wis. Admin. Code HCF 1011 (Rev. 08/05)

WISCONSIN MEDICAID PHYSICIAN CERTIFICATION / RECERTIFICATION OF TERMINAL ILLNESS

Wisconsin Medicaid requires certain information to enable Medicaid to authorize and pay for medical services provided to eligible recipients. Recipients are required to give providers full, correct, and truthful information for the submission of correct and complete claims for Medicaid reimbursement. This information should include, but is not limited to, information concerning eligibility status, accurate name, address, and Medicaid identification number (HFS 104.02[4], Wis. Admin. Code). Under s. 49.45(4), Wis. Stats., personally identifiable information about Medicaid applicants and recipients is confidential and is used for purposes directly related to Medicaid administration such as determining eligibility of the applicant or processing provider claims for reimbursement. Failure to supply the information requested by the form may result in denial of Medicaid payment for the services. If a verbal certification is obtained within two calendar days after the initial six-month period of care begins, the hospice has up to eight calendar days after the six-month period begins to obtain a written physician certification of a recipient’s terminal illness. If the physician’s written certification is not obtained within eight calendar days, only services provided on or after the signature date of the physician’s certification are reimbursed. Provision of the information requested on this form is mandatory. However, the use of this version of the form is voluntary. Providers may develop their own version of this form as long as it includes all the information on this form. Instructions: Type or print clearly. Keep this information in the recipient’s records; do not send it to Wisconsin Medicaid.

SECTION I — CERTIFICATION STATEMENT Name — Recipient Recipient’s Medicaid Identification Number

Description of Disease

We (or I) certify that the above-named Medicaid recipient is terminally ill with the disease described above. His or her life expectancy is six (6) months or less if the disease runs its normal course. SIGNATURE — Hospice Medical Director or Designee Certification Date

SIGNATURE — Attending Physician Certification Date Medicaid Provider Number Date Signed

SECTION II — RECERTIFICATION STATEMENT

I recertify that the above patient is still considered terminally ill with the above-stated disease and has a life expectancy of six (6) months or less if the disease runs its normal course. SIGNATURE — Hospice Medical Director or Designee Recertification Date Date Signed


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Appendix

Appendix 4Notification of Medicaid Hospice Benefit Election

(for photocopying)

(A copy of the Notification of Medicaid Hospice Benefit Election formis located on a following pages.)


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(This page was intentionally left blank.)


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WISCONSIN MEDICAID NOTIFICATION OF MEDICAID HOSPICE BENEFIT ELECTION

Wisconsin Medicaid requires certain information to enable Medicaid to authorize and pay for medical services provided to eligible recipients. Recipients are required to give providers full, correct, and truthful information for the submission of correct and complete claims for Medicaid reimbursement. This information should include, but is not limited to, information concerning eligibility status, accurate name, address, and Medicaid identification number (HFS 104.02[4], Wis. Admin. Code). Under s. 49.45(4), Wis. Stats., personally identifiable information about Medicaid applicants and recipients is confidential and is used for purposes directly related to Medicaid administration such as determining eligibility of the applicant or processing provider claims for reimbursement. Failure to supply the information requested by the form may result in denial of Medicaid payment for the services. This form is mandatory; use an exact copy of this form. Wisconsin Medicaid will not accept alternate versions (i.e., retyped or otherwise reformatted) of this form. Instructions: Type or print clearly. This form has two pages; always complete Section I and any other sections of the form that apply to the recipient. When complete, mail the form to the following address: Wisconsin Medicaid Recipient Services PO Box 6678 Madison WI 53716-0678

SECTION I — COMPLETE FOR ALL HOSPICE RECIPIENTS

The recipient named on this form has elected to receive Medicaid hospice benefits. The recipient signed the Recipient Election of Medicaid Hospice Benefit form, HCF 1009, on the date indicated below and has been certified by a physician as having six (6) months or less life expectancy if the illness follows its usual course. The recipient’s hospice has the Physician Certification/Recertification of Terminal Illness form, HCF 1011, on file.

Name — Recipient (First, middle initial, last) Recipient’s Medicaid Identification Number Date Election Form Signed

Name — Hospice Hospice’s Medicaid Provider Number

Name — Attending Physician Attending Physician’s Medicaid Provider No. Is the Attending Physician Employed by the Hospice? ! Yes ! No

SECTION II — COMPLETE FOR RECIPIENTS RESIDING IN A NURSING HOME AT THE TIME OF HOSPICE ELECTION

The hospice and nursing home named below are in agreement that the hospice shall provide hospice services, while the nursing home shall provide room and board services as defined under COBRA, P.L. 99-272. “Room and board” includes the performance of personal care services, including assistance in the activities of daily living, socializing activities, administration of medication, maintaining the cleanliness of the resident’s room, and supervision and assistance in the use of durable medical equipment (DME) and prescribed therapies. Wisconsin Medicaid will reimburse the hospice for room and board at 95 percent of the nursing home’s current skilled nursing facility (SNF) daily rate, for the appropriate number of days, for the hospice recipient in the nursing home. The hospice will in turn reimburse the nursing home. Name — Nursing Home Nursing Home’s Medicaid Provider Number Level of Care

Continued


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NOTIFICATION OF MEDICAID HOSPICE BENEFIT ELECTION Page 2 of 2 HCF 1008 (Rev. 08/05)

SECTION III — COMPLETE FOR RECIPIENTS ENTERING A NURSING HOME AFTER HOSPICE ADMISSION

The hospice and nursing home named below are in agreement that the hospice shall provide hospice services, while the nursing home shall provide room and board services as defined under COBRA, P.L. 99-272. “Room and board” includes the performance of personal care services, including assistance in the activities of daily living, socializing activities, administration of medication, maintaining the cleanliness of the resident’s room, and supervision and assistance in the use of DME and prescribed therapies. Wisconsin Medicaid will reimburse the hospice for room and board at 95 percent of the nursing home’s current SNF daily rate, for the appropriate number of days, for the hospice recipient in the nursing home. The hospice will in turn reimburse the nursing home.

Name — Nursing Home

Nursing Home’s Medicaid Provider Number Date Admitted to Nursing Home

SECTION IV — COMPLETE FOR REVOCATION OF MEDICAID HOSPICE BENEFITS

The recipient named below has decided to discontinue the Medicaid hospice benefit on the date indicated. Medicaid Identification Number — Recipient Hospice’s Medicaid Provider Number Date Recipient Signed

Revocation Form

Name — Attending Physician Attending Physician’s Medicaid Provider No. Is the Attending Physician Employed by the Hospice? ! Yes ! No


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Appendix

Appendix 5Recipient Election of Medicaid Hospice Benefit

(for photocopying)

(A copy of the Recipient Election of Medicaid Hospice Benefit formis located on the following page.)


for current policy


WISCONSIN MEDICAID RECIPIENT ELECTION OF MEDICAID HOSPICE BENEFIT

Wisconsin Medicaid requires certain information to enable Medicaid to authorize and pay for medical services provided to eligible recipients. Recipients are required to give providers full, correct, and truthful information for the submission of correct and complete claims for Medicaid reimbursement. This information should include, but is not limited to, information concerning eligibility status, accurate name, address, and Medicaid identification number (HFS 104.02[4], Wis. Admin. Code). Under s. 49.45(4), Wis. Stats., personally identifiable information about Medicaid applicants and recipients is confidential and is used for purposes directly related to Medicaid administration such as determining eligibility of the applicant or processing provider claims for reimbursement. Failure to supply the information requested by the form may result in denial of Medicaid payment for the services. Provision of the information requested on this form is mandatory; however, the use of this version of the form is voluntary. Providers may develop their own version of this form as long as it includes all the information on this form. Instructions: Type or print clearly. Keep this information in the recipient’s records; do not send it to Wisconsin Medicaid. Name — Recipient Name — Hospice Hospice’s Medicaid Provider Number

Name — Attending Physician Start Date for Hospice Services

I, the recipient named above, choose to receive hospice care from the hospice program named above. I acknowledge and understand the following: • The hospice program is palliative, not curative, in its goals. This means that the program does not

attempt to cure disease, but emphasizes the relief of symptoms such as pain, physical discomfort, and emotional stress that may accompany a life-threatening illness.

• By choosing Medicaid hospice benefits, I agree to receive all services from the hospice and attending physician I designated above.

• I can choose to discontinue hospice care at any time. To discontinue, I must complete a revocation statement. I can obtain this statement from the hospice coordinator.

• If I choose to withdraw from my Medicaid hospice benefit, I understand that I may re-elect hospice at a later time.

• I can choose to receive hospice care from another hospice program at any time. To change programs, I must first confirm that the hospice to which I wish to be admitted can admit me and on what date. I must inform my current hospice program of my wishes so that arrangements for the transfer can be made. I must document the date I wish to discontinue care from my current hospice, the name of the hospice from which I wish to receive care, and the date that care will start.

Acknowledging and understanding the above, I authorize the above-named hospice to begin providing Medicaid-covered services on the date indicated above. I designate the physician named above as my attending physician. SIGNATURE — Recipient or Legal Representative Date Signed

SIGNATURE — Witness Name — Witness Date Signed


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Appendix

Appendix 6Hospice Benefit Revocation

(Non-recertification)/Voluntary Discharge(for photocopying)

(A copy of the Hospice Benefit Revocation [Non-recertification]/VoluntaryDischarge form is located on the following page.)


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WISCONSIN MEDICAID HOSPICE BENEFIT REVOCATION

(NON-RECERTIFICATION) / VOLUNTARY DISCHARGE Wisconsin Medicaid requires certain information to enable Medicaid to authorize and pay for medical services provided to eligible recipients. Recipients are required to give providers full, correct, and truthful information for the submission of correct and complete claims for Medicaid reimbursement. This information should include, but is not limited to, information concerning eligibility status, accurate name, address, and Medicaid identification number (HFS 104.02[4], Wis. Admin. Code). Under s. 49.45(4), Wis. Stats., personally identifiable information about Medicaid applicants and recipients is confidential and is used for purposes directly related to Medicaid administration such as determining eligibility of the applicant or processing provider claims for reimbursement. Failure to supply the information requested by the form may result in denial of Medicaid payment for the services. Provision of the information requested on this form is mandatory. However, the use of this version of the form is voluntary. Providers may develop their own version of this form as long as it includes all the information on this form. Instructions: Type or print clearly. Keep this information in the recipient’s records; do not send it to Wisconsin Medicaid.

Name — Recipient Name — Hospice

I, the recipient, (check one): ! Understand that my attending physician and the Hospice Interdisciplinary Team have determined that at

this time I do not meet the Medicaid criteria for the hospice benefit. The basis for this has been explained to me.

! Choose to revoke election for Medicaid coverage for hospice care provided by the hospice program named above.

Hospice coverage will continue through _________________ (MM/DD/YY). Medicaid hospice reimbursement will continue through ________________ (MM/DD/YY).

I understand that my Medicaid hospice benefits will cease. If it is determined that I once again meet the Medicaid criteria for the hospice benefit, I may re-elect Medicaid hospice coverage.

I understand that the Medicaid health care benefits I waived to receive Medicaid hospice coverage will resume on __________________ (MM/DD/YY, the day following the last day of hospice coverage).

! I agree / ! I do not agree (check one) to waive the 14-day waiting period required by the State of Wisconsin for voluntary discharge from the hospice named above.

SIGNATURE — Recipient or Legal Representative Date Signed

SIGNATURE — Hospice Representative Date Signed


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Hospice Services Handbook ! October 2005 47

Appendix

Appendix 7Allowable Revenue Codes for Hospice Care

Wisconsin Medicaid uses nationally recognized four-digit revenue codes for hospice services. Hospices are required to usethe allowable revenue codes for all dates of service. Revenue codes are subject to change. The current national revenuecodes are listed below.

National Revenue Code

Description

0169 Room and board — Other (for skilled nursing facility) 0651 Hospice services — Routine home care (up to 7.5 hours/day) 0652 Hospice services — Continuous home care (8-24 hours/day) 0655 Hospice services — Inpatient respite care 0656 Hospice services — General inpatient care


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Hospice Services Handbook ! October 2005 49

Appendix

Appendix 8Rounding Guidelines for Continuous Care

The following chart illustrates the rules of rounding. Hospices are reminded that continuous care is billed for eight or morehours of care per day.

Time (InMinutes)

Unit(s)Billed

1-30 .531-44 .545-60 1.061-74 1.075-90 1.5

91-104 1.5105-120 2.0121-134 2.0


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Appendix

Appendix 9Services Provided Outside the Hospice Benefit

This appendix presents guidelines for claims submitted for services other than hospice services and allowed attendingphysician services. Wisconsin Medicaid will only reimburse services unrelated to the terminal illness that are otherwisemedically necessary, Medicaid-covered benefits.

Provider Category Separately Reimbursable for

Hospice Recipients

Not Separately Reimbursable for

Hospice Recipients

Consultant Reviewed

Ambulatory surgical center X

Audiology X

Case management X

Chiropractic X

Community support program X

Certified registered nurse anesthetist services

X

Dental X

End-stage renal disease X

Family planning X

HealthCheck X

Hearing instruments X

Home health X

Intermediate care facility/ mentally retarded

X

Institutions for mental disease X

Inpatient hospital X

Laboratory X

Medical vendor X

Medical day treatment X

Nursing facility X

Optical care (optometrist, optician) X

Outpatient hospital X

Outpatient mental health/substance abuse

X


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Appendix

Appendix 10Sample Adjustment/Reconsideration Request for

Retroactive Nursing Home Rate Adjustment

I M Hospice Provider

Ima Recipient

87654321

0987654321

MM/DD/YY 123456789012345

X

To obtain retroactive rate increase for nursing home room and board.

I M Hospice Provider MM/DD/YY

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Health Care Financing HCF 13046 (Rev. 08/05)

STATE OF WISCONSIN

WISCONSIN MEDICAID ADJUSTMENT / RECONSIDERATION REQUEST

Instructions: Type or print clearly. Refer to the Adjustment/Reconsideration Request Completion Instructions, HCF 13046A, for information about completing this form. SECTION I — BILLING PROVIDER AND RECIPIENT INFORMATION 1. Name — Billing Provider 2. Billing Provider's Medicaid Provider Number

3. Name — Recipient 4. Recipient Medicaid Identification Number

SECTION II — CLAIM INFORMATION 5. Remittance and Status (R/S) Report Date / Check Issue Date 6. Internal Control Number / Payer Claim Control Number

# Add a new service line(s) to previously paid / allowed claim (in Elements 7-15, enter information to be added). 7. Date(s) of Service

From To

8. POS

9. Procedure / NDC / Revenue Code

10. Modifiers 1-4

Mod 1 Mod 2 Mod 3 Mod 4

11. Billed Amount

12. Unit Quantity

13. Family Plan

14. EMG

15. Performing Provider

SECTION III — ADJUSTMENT INFORMATION 16. Reason for Adjustment # Consultant review requested. # Recoup entire Medicaid payment. # Other insurance payment (OI-P) $_________. # Copayment deducted in error # Recipient in nursing home. # Covered days _____. # Emergency. # Medicare reconsideration. (Attach the Medicare remittance information.) # Correct service line. (Provide specific information in the comments section below or attach a corrected claim.) # Other / comments. 17. SIGNATURE — Provider 18. Date Signed

19. Claim Form Attached (Optional) # Yes # No

Mail to: Wisconsin Medicaid Claims and Adjustments 6406 Bridge Rd Madison WI 53784-0002

Maintain a copy of this form for your records.


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Index

IndexBilled amounts, 22

Billing increments, 22

Claims submissionElectronic, 21Paper, 21

Coordination of benefits, 21

Copayment, 9

Diagnosis codes, 22

Durable medical equipment, 13

Fee schedule, 22

FormsAdjustment/Reconsideration Request sample,

53Ordering, 17Retention and submission, 17UB-92 Claim Form instructions, 27UB-92 Claim Form sample, 35

HospiceCap on overall reimbursement, 24Certification, 6Core functions, 5Definition, 5Designated primary provider, 8Discontinuation or transfer, 8Responsibilities, 7Scope of service, 6Supplemental services, 5

Hospice service categoriesContinuous care, 11General inpatient care, 12Inpatient respite care, 11Routine care, 11

Hospice-specific formsHospice Benefit Revocation, 8, 45Notification of Medicaid Hospice Benefit

Election, 16, 39Physician Certification of Terminal Illness, 15,

37Plan of care, 16Recipient Election of Medicaid Hospice

Benefit, 15, 43

Nursing homePatient liability, 24Recipient residing in, 8Reimbursement, 23Room and board, 12

Personal care services, 13

Plan of care, 16

Prior authorizationPersonal care services, 19

RecipientHospice enrollment, 7Requirements, 8Residing in nursing home, 8

Reimbursement not available, 13

Revenue codes, 22, 47

Rounding guidelines, 49

Services outside the hospice benefit, 51


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