Billing for Denial of Hospice Room and Board Charges

Under the Medicare hospice benefit, room and board charges are statutorily excluded and never covered by Medicare, except when provided in an inpatient setting (inpatient respite or general inpatient care). Room and board charges should only be submitted to Medicare when a denial is necessary to bill Medicaid or other insurance.

Effective for claims submitted on or after July 1, 2012, Change Request 7677 states that hospice providers wishing to receive a line item denial for room and board charges may submit the charges as non-covered using revenue code 0659 with HCPCS A9270 and modifier GY on an otherwise covered hospice claim.

Key Points:

• Providers may not submit a separate claim for a denial for room and board charges
• Room and board charges must be included on the regular hospice claim
  • Room and board charges will be submitted as non-covered on the claim
  • Condition Code 20 is not used on a claim that includes room and board charges
• Hospice providers may do an adjustment of an already processed claim, adding the room and board charges as non-covered if the hospice wishes to receive a line item denial for room and board charges
• Note: Timely Filing Requirements apply to all covered and non-covered services billed to Medicare

Billing Instructions:
Non-covered room and board charges will be included along with covered charges on the regularly submitted hospice claim. Therefore, in addition to the usual hospice claim information include the following UB-04 Field Locators (FL):

• FL 42 – Revenue Code: Enter revenue code 0659 for room and board
• FL 44 – HCPCS: Enter the HCPC code A9270 on the 0659 revenue code line for room and board
• FL 44 – HCPCS Modifiers: Enter the modifier GY on the 0659 revenue code line for room and board
• FL 48 – Noncovered Charges: Enter the room and board charges on the 0659 revenue code lines for room and board
• FL 80 – Remarks: Enter a brief remark indicating the non-covered charges are for room and board

Providers should ensure that when submitting claims electronically that the total units associated with the room and board charges are also submitted as non-covered.

Medicare contractors will include claim adjustment reason code 96 with a message on the Remittance Advice (RA) to indicate a denial of hospice room and board charges Group code PR (patient responsibility) will also be displayed on the RA. The Medicare Summary Notice (MSN) message 16.10 - Medicare does not pay for this item or service will be issued to the beneficiary.

References:

• CMS Change Request (CR) 7677
• Medicare Claims Processing Manual (CMS Pub. 100-04)
  • Chapter 1, Section 60
  • Chapter 2, Section 100
  • Chapter 25
• Medicare Benefit Manual (CMS Pub. 100-02)
  • Chapter 9, Section 20.3