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G-Codes in Home Health and Hospice

Effective January 1, 2016, CMS established new G-codes to differentiate levels of nursing services provided during a hospice stay and a home health episode of care. These two G-codes and the retirement of G0154 will be effective for hospice dates of service on and after January 1, 2016 and for home health episodes of care ending on or after January 1, 2016: Service is provided by an RN shall be coded as G0299, Service is provided by an LPN shall be coded as G0300.

 

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.

Frequently Asked Questions

What G-codes do we use to define skilled nursing services in home health and hospice settings?

Effective January 1, 2016, CMS established two additional G-codes to differentiate levels of nursing services provided during a hospice stay and a home health episode of care. These two G-codes and the retirement of G0154 are effective for hospice dates of service on and after January 1, 2016 and for home health episodes of care ending on or after January 1, 2016: Service is provided by an RN shall be coded as G0299, Service is provided by an LPN shall be coded as G0300.

  • G0154 Direct skilled services of a licensed nurse (LPN or RN) in the home health or hospice setting, each 15 minutes. – Retirement of G0154 will be effective on institutional claims for hospice dates of service on or after January 1, 2016 and for home health episodes of care ending on or after January 1, 2016.
  • G0299 Direct skilled services of a licensed nurse (RN) in the home health or hospice setting. – effective on institutional claims for hospice dates of service on or after January 1, 2016
  • G0300 Direct skilled services of a licensed nurse (LPN) in the home health or hospice setting – effective home health episodes of care ending on or after January 1, 2016

Effective January 1, 2011, CMS established additional G-Codes for the reporting of the skilled services of a licensed nurse in the management and evaluation of the care plan; another for the observation and assessment of a patient’s conditions when only the specialized skills of a licensed nurse can determine the patient’s status until the treatment regimen is essentially stabilized; and another for the reporting of the training or education of a patient, a patient’s family, or caregiver.

  • G0162 Skilled services by a licensed nurse (RN only) for management and evaluation of the plan of care, each 15 minutes (the patient’s underlying condition or complication requires an RN to ensure that essential non-skilled care achieves its purpose in the home health or hospice setting).
  • G0163 Skilled services of a licensed nurse (LPN or RN) for the observation and assessment of the patient’s condition, each 15 minutes (the change in the patient’s condition requires skilled nursing personnel to identify and evaluate the patient’s need for possible modification of treatment in the home health or hospice setting).
  • G0164 Skilled services of a licensed nurse (LPN or RN), in the training and/or education of a patient or family member, in the home health or hospice setting, each 15 minutes.

Can I use more than one G-Code per Visit?

HHAs must not report more than one G-code for the nursing visit regardless of the variety of nursing services provided during the visit.

CMS recognizes that, in the course of a visit, a nurse or qualified therapist could likely provide more than one of the nursing or therapy services reflected in the  and revised codes above. Similarly, the HHA must not report more than one G-code for the therapy visit, regardless of the variety of therapy services provided during the visit. In cases where more than one nursing or therapy service is provided in a visit, the HHA must report the G-code which reflects the service for which the clinician spent most of his/her time. For instance if direct skilled nursing services are provided, and the nurse also provides training/education of a patient or family member during that same visit, we would expect the HHA to report the G-code which reflects the service for which most of the time was spent during that visit. Similarly, if a qualified therapist is performing a therapy service and also establishes a maintenance program during the same visit, the HHA should report the G-code which reflects the service for which most of the time was spent during that visit.

What does the Medicare Benefit Policy Manual Chapter 7 have as outlined Skilled Therapy Services?

Section 40.2.1 General Principles Governing Reasonable and Necessary Physical Therapy, Speech-Language Pathology Services, and Occupational Therapy identifies that skilled therapy services must be reasonable and necessary to the treatment of the patient’s illness or injury or to the restoration or maintenance of function affected by the patient’s illness or injury. “It is necessary to determine whether individual therapy services are skilled and whether, in view of the patient’s overall condition, skilled management of the services provided is needed although many or all of the therapeutic services needed to treat the illness or injury do not require the skills of a therapist.” Chap 7, 40.2,1

What G-codes do we use to define physical therapy services in home health and hospice settings?

Effective January 1, 2011, use the following G-codes for the reporting of physical therapy, occupational, and speech-language therapy services provided by qualified therapists.

  • G0151 Services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes.
  • G0152 Services performed by a qualified occupational therapist in the home health or hospice setting, each 15 minutes.
  • G0153 Services performed by a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes.

Effective January 1, 2011, CMS added additional G-codes (G0157 and G0158) for the reporting of physical therapy and occupational therapy services provided by qualified therapy assistants.

  • G0157 Services performed by a qualified physical therapist assistant in the home health or hospice setting, each 15 minutes.
  • G0158 Services performed by a qualified occupational therapist assistant in the home health or hospice setting, each 15 minutes.

CMS also added and required the use of three additional G-codes for the reporting of the establishment or delivery of therapy maintenance programs by qualified therapists. The following are descriptions for those additional G-codes, for the reporting of the establishment or delivery of therapy maintenance programs by therapists:

  • G0159 Services performed by a qualified physical therapist, in the home health setting, in the establishment or delivery of a safe and effective physical therapy maintenance program, each 15 minutes.
  • G0160 Services performed by a qualified occupational therapist, in the home health setting, in the establishment or delivery of a safe and effective occupational therapy maintenance program, each 15 minutes.
  • G0161 Services performed by a qualified speech-language pathologist, in the home health setting, in the establishment or delivery of a safe and effective speech-language pathology maintenance program, each 15 minutes.

Can my qualified physical therapist open a case and then turn it over to an assistant?

Effective April 1, 2011, agencies can no longer have a qualified PT open a case and in effect turn it over to an assistant.  CMS believes it is paying for qualified therapy and expects to see the results of having the higher educated therapist actively involved with the patient’s care. This is one reason for the mandated qualified therapist to functionally assess the patient on the 13th and 19th therapy visit.

Helpful Tip


Your documentation must support the visit type and that visit type had best support the Plan of Care (POC). Visit notes will need to clearly justify the visit and show the value as it relates to the orders/goals of the POC. It will be easier for an auditor to see two or three recertifications of a chronic disease and pull out visits by type and ask specific questions and deny the visits.

Remember, an episode doesn’t need to be fully denied, just having 5 of 14 visits denied could realize a $1000 episodic loss, depending on the patient HIPPS/HHRG

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