G-Codes in Home Health and Hospice
FY 2016 G-Code Policy Changes in Home Health and Hospice
Effective January 1, 2016, As described in CR 9201, CMS is implemented a Service Intensity Add-On (SIA) payment for skilled visits (provided by a registered nurse (RN) and/or medical social worker) provided during last seven days of life during a hospice election (in addition to the current per diem rate for the Routine Home Care (RHC) level of care). The SIA payment would be paid in addition to the current per diem rate for the RHC level of care.
The SIA policy necessitates the creation of two G-codes for nursing for use when billing skilled nursing visits (revenue center 055x), one for a RN and one for a Licensed Practical Nurse (LPN). During periods of crisis, such as the precipitous decline before death, patient needs intensify and RNs are more highly trained clinicians with commensurately higher payment rates who can appropriately meet those increased needs. Moreover, Medicare rules at §418.56(a)(1) require the RN member of the hospice interdisciplinary group to be responsible for ensuring that the needs of the patient and family are continually assessed. Medicare expects that at end of life, the needs of the patient and family will need to be frequently assessed; thus the skills of the interdisciplinary group RN are required. As such, the SIA policy was finalized to recognize additional payment at end-of-life for services provided by RNs and not LPNs.
In order to quantify the amount of RN services provided to a patient, hospice claims must differentiate between nursing services provided by an RN and nursing services provided by an LPN. Therefore, CMS established codes to distinguish between RN services [G0299] and LPN services [G0300]. The current single G-code of G0154 for “Direct skilled nursing services of a licensed nurse (LPN or RN) in the home health or hospice setting” will be retired. Since G0154 is used in both the home health and hospice settings, home health agencies and hospices will be required to utilize G0299 for “direct skilled nursing services of a registered nurse (RN) in the home health or hospice setting” and G0300 “direct skilled nursing of a licensed practical nurse (LPN) in the home health or hospice setting”.
History of G-Codes in Home Health and Hospice
The March 2009 Medicare Advisory Payment Commission (MedPAC) report recommended that CMS improve the HH PPS to mitigate vulnerabilities such as payment incentives to provide unnecessary services. The need for more specific resource use data to fully address these vulnerabilities was identified.
In their March 2010 report, MedPAC recommended that CMS improve the HH PPS, and expressed concern with the significant variation in the services provided to beneficiaries. MedPAC also suggested that CMS adjust the HH PPS case-mix weights to more accurately reflect services required. In order to address MedPAC’s concerns and to more fully understand the services which are being provided, they identified a need to collect additional data on the HH claim regarding the specific sorts of therapy and nursing services being provided. Specifically, a number of the new and revised codes described below differentiated between therapy services provided by a qualified therapist versus a therapy assistant. A qualified therapist is one who meets the personnel requirements in the Conditions of Participation (CoPs) at 42 CFR 484.4. Additionally, other new and revised codes were provided for the reporting of training and/or education of the patient or family member and the skilled nursing services of a licensed nurse for the management and evaluation of the care plan and the observation and assessment of the patient’s condition, when normal “direct” skilled nursing services of a licensed nurse are not provided.
Effective January 1, 2011, In order for CMS to collect more specific information regarding the sort of services provided to home health patients, CMS revised the current descriptions for existing G-codes for physical therapists (G0151), occupational therapists (G0152), and speech-language pathologists (G0153), to include in the descriptions that they are intended for the reporting of services provided by a qualified physical or occupational therapist or speech language pathologist.
CMS required Home Health Agencies (HHAs) to report additional and more specific data for therapy and nursing visits on the HH claim beginning January 1, 2011. While many of the codes (described below) included the hospice setting in their description, CMS did not require hospices to use of the G-codes described below at this time, as Medicare systems limitations prevented the use of the codes on hospice claims.. Future instruction was planned to expand the optional use of these codes to hospice claims. Existing codes that included the hospice setting in their description continued to be required of hospices reporting those services.
Summary of CMS Policy on the Utilization of G Codes in Home Health and Hospice
Medicare makes payment under the Home Health Prospective Payment System (HH PPS) on the basis of a national standardized 60-day episode payment rate that is adjusted for the applicable case-mix and wage index. The national standardized 60-day episode rate pays for the delivery of home health services, which includes the six home health disciplines (skilled nursing, home health aide, physical therapy, speech-language pathology, occupational therapy, and medical social services). G-Codes are used to differentiate between the six home health disciplines. Claims must report all home health services provided to the beneficiary within the episode. Each service must be reported in line item detail.