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Important Information for Hospice Providers: Automated Processing of Hospice Room and Board Private Room Add-on Payments
Background:
In accordance with Ohio Revised Codes 5165.01 and 5165.158, the Ohio Department of Medicaid (ODM) began reimbursing private rooms at qualifying nursing facilities (NFs) for claims with dates of service (DOS) starting December 18, 2024. Hospice providers are eligible to receive 95% of the private room add-on rate for Medicaid residents enrolled in hospice who are receiving services in an approved NF private room.
A system modification is being planned for October that will automate the processing of Medicaid fee-for-service (FFS) hospice room and board private room add-on claims to align with how managed care claims are billed. Each date of service should continue to be added on a separate line and the total billed charges for each line should include 95% of the NF daily rate plus 95% of the appropriate private room add-on rate.
What will be changing?
- Hospice providers billing for room and board with a private room add-on payment will no longer be required to email the private room add-on claims to ODM for manual review and reprocessing.
- Hospice providers should bill using the following code/modifier combinations to receive the private room add-on payments.
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Private Room Beds
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Bill Code
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Modifier
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95% of Private Room Add-on
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Category 1
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T2046
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XP
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$28.50
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Category 2
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T2046
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XU
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$19.00
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The private room add-on payment will not be added to the hospice room and board reimbursement in the following situations:
- The NF’s NPI that is listed on the hospice enrollment Hospice Long-Term Care Facility (HLTCF) panel for the corresponding DOS, has not been approved as a private room provider for category 1 and/or 2 beds for the dates of service billed.
- The appropriate corresponding modifier is not listed on each claim line eligible for the private room add-on payment. In this scenario, the claim line(s) will pay the routine room and board rate without the add-on payment.
- ODM has reached the annual funding limit for the NF private room incentive payment.
Next steps:
- Effective immediately, hospice providers may start billing using the code/modifier combinations as directed above.
- During the month of October, providers will need to continue to email Hospice Policy in order for the private room add-on claims to be manually reviewed and processed.
- By the end of October, claims billed with the private room add-on code and modifier combinations should start processing automatically.
Additional information:
- Private room add-on incentive payments will be paid in addition to the routine hospice room and board reimbursement for the approved private room beds until ODM reaches the funding limit for the private room incentive.
- Private room add-on incentive payments are not reimbursable on the same date of service as a ventilator or ventilator weaning service.
- Room and board are not reimbursable on the date of death; therefore, the private room add-on incentive payment is not reimbursable on the date of death.
- The current listing of facilities approved for private room incentive reimbursement with NPIs can be found on the Ohio Department of Medicaid nursing facilities web page under “Private Room News.”
Questions?
Fee for service questions should be directed to the Hospice mailbox at MCDHospice@medicaid.ohio.gov.
For Medicaid managed care and MyCare members, please contact the appropriate managed care plan.
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