Medicaid hospice, respite benefit - CSHCS

What Is Hospice Care?

Medicaid participants can receive hospice care when they are terminally ill. “Terminally ill” means the patient has been diagnosed with a medical condition that reduces their life expectancy and is near the end of life. Each State can decide the length of the life expectancy a patient must have to receive hospice care under Medicaid. Some States, including Kentucky[1] and Texas,[2] use the Medicare definition of “terminally ill” as a medical prognosis with a life expectancy of 6 months or less if the illness runs its normal course.[3] Other States, like New York, define “terminally ill” as a medical prognosis with a life expectancy of 12 months or less for hospice eligibility.[4] Your State may allow the election of the hospice benefit sooner. Check with your SMA if you have questions.

The goal of hospice care is to:

• Improve quality of life; and
• Help manage a terminal illness and related conditions


Under Medicare/Medicaid, hospice is a comprehensive program of care delivered in a person’s home. The Hospice Medicare and/or Medicaid Benefit provides all the reasonable and necessary medical and support services for the management of a terminal illness.


• physician services provided by LifeCare Hospice Medical Director
• nursing care from LifeCare Hospice nurses
• medical equipment and supplies
• medicines for symptom management and pain relief
• short-term (hospitalization) inpatient care for symptom management
• home health aide services
• specialized therapies such as physical therapy, speech therapy, etc.
• medical social services
• counseling, including dietary and bereavement counseling
• respite care: up to 5 days stay in a contract facility
• continuous care is utilized on a short-term basis to maintain a person’s comfort in the home.


 Hospice care is available under this Benefit only if:
• the patient is eligible for Medicare Hospital Insurance (Part A), or Medicaid.
• the patient’s doctor and the hospice medical director certify that the patient is terminally ill, with a life expectancy of six months or less.
• the patient signs a statement choosing The Hospice Medicare and/or Medicaid Benefit.
• the patient receives care from a Medicare-approved hospice program.


Medicare/Medicaid Benefit Periods: Special benefit periods apply to hospice care. These periods are as follows:

First Benefit Period -- 90-days

Second Period -- 90-days

Unlimited number of subsequent 60-day periods

The benefit periods may be used consecutively or at intervals. Regardless of whether they are used one right after the other or at different times, the patient must be recertified with a life expectancy of six months or less, before the beginning of each benefit period.


To assure compliance with Medicare/Medicaid rules and regulations, all patients receiving the Hospice Medicare/Medicaid Benefit must be evaluated near the end of each benefit period. Recertification is a decision process which is completed by the Medical Director with physician, patient/family, and Hospice Team input. The outcome determines a patient’s eligibility for continued hospice services into the next benefit period. The same rules apply during recertification that were followed at the time of admission.

As a part of the recertification process, your attending physician may request that certain diagnostic tests be completed or repeated. This will assist the Medical Director and your physician in making their decision about your case.

If, at recertification, the patient has improved – Medicare/Medicaid rules state that the Hospice is required to suspend hospice care. If hospice care is suspended and in the future the patient declines, hospice care may be started again.

Should you have questions or concerns about the recertification process, please feel free to contact your Nurse Case Manager, or the Patient Care Coordinator. Should you disagree with the Medical Director’s decision, you may appeal to Medicare by filing a Demand Bill. Please call the Patient Care Coordinator for information, should you wish to appeal.

What Does the Medicaid Hospice Program Cover?

Hospice services are covered as part of your Medicaid benefits.[22] Services are provided by a team to meet your needs. The hospice team may include you, your family, and others who can help meet your physical, psychosocial, spiritual, and emotional needs. Your needs are written in a plan of care (POC), also called a plan.

The benefits listed below are examples of hospice services you may receive:

• Physician services provided by the hospice agency;
• Nursing care;
• Medical equipment;
• Medical supplies;
• Drugs for symptom control and pain relief;
• Hospice aide and homemaker services;
• Physical therapy;
• Occupational therapy;
• Speech-language pathology services;
• Social worker services;
• Dietary counseling; and
• Short-term inpatient care for pain control, symptom management, and respite care.

Hospice benefits may also include anything needed to manage your terminal illness and related conditions that is normally covered by Medicaid. The following hospice services must be provided directly by hospice employees:

• Nursing care;
• Physician services;
• Medical social services; and
• Counseling.

Other hospice services may be provided, such as visits by a physician who specializes in your illness.Hospice benefits may be different in each State. Check with your SMA about hospice benefits in the area.


The CSHCS hospice benefit provides assistance to a family/beneficiary when end of life care related to the beneficiary’s CSHCS qualifying diagnosis is appropriate. Hospice is intended to address the medical needs of the beneficiary with a terminal illness whose life expectancy is limited to six months or less.

Hospice services must be prior authorized. Prior authorization requests require medical documentation from the beneficiary’s enrolled CSHCS subspecialist who is authorized (i.e., listed on the beneficiary’s CSHCS authorized provider file) to treat the terminal illness. The medical documentation must include all of the following:

* A statement of the terminal diagnosis.

* A statement that the beneficiary has reached the terminal phase of illness where the CSHCS subspecialist deems end of life care necessary and appropriate.

* Documentation of the need to pursue end of life care.

* A statement of limited life expectancy of six months or less.

* A proposed plan of care to address the service needs of the beneficiary that is:

* less than 30 days old;

* consistent with the philosophy/intent of the CSHCS hospice benefit as described above;

* clinically and developmentally appropriate to the beneficiary’s needs and abilities;

* representative of the pattern of care for a beneficiary who has reached the terminal phase of illness; and

* signed by the CSHCS subspecialist authorized to treat the terminal illness.

The prior authorization time period does not exceed six months. To continue hospice services beyond six months, a new prior authorization request with medical documentation must be submitted as described above.

Hospice may not be authorized and/or continued for a beneficiary when one or more of the following is true:

* The medical documentation no longer supports the above criteria (e.g., change in condition, change in the plan of care, etc.).

* The family chooses to discontinue hospice.

* The medical services being rendered by the hospice provider are available through another benefit.

Requests for hospice must be made in writing to CSHCS. (Refer to the Directory Appendix for contact information.) CSHCS responds to all prior authorization requests for hospice services in writing.


Respite services provide limited and temporary relief for families caring for beneficiaries with complex health care needs when the care needs require nursing services in lieu of the trained caregivers. Services are provided in the family home by hourly skilled and licensed nursing services as appropriate. To be eligible and authorized for respite, MDHHS must determine the beneficiary to have:

* Health care needs that meet the following criteria:

* That skilled nursing judgments and interventions be provided by licensed nurses in the absence of trained and/or experienced parents/caregivers responsible for the beneficiary’s care;

* That the family situation requires respite; and

* That no other community resources are available for this service.

* No other publicly or privately funded hourly skilled nursing services in the home that would be duplicated by the CSHCS respite benefit.

* Service needs which can reasonably be met only by the CSHCS Respite benefit, not by another service benefit.

Respite is reimbursed when provided by a Medicaid enrolled home health agency, a Medicaid enrolled registered nurse (RN) who is licensed to practice in the state of Michigan, or a Medicaid enrolled licensed practical nurse (LPN) who is licensed to practice in the state of Michigan and working under supervision according to the Michigan Public Health Code. It is the responsibility of the LPN to secure the appropriate supervision and maintain documentation that identifies the supervising professional.

A maximum of 180 hours of CSHCS Respite services may be authorized per family during the 12-montheligibility period. When there is more than one respite-eligible beneficiary in a single home, the respite  service is provided by one nurse at an enhanced reimbursement rate for the services provided to multiple beneficiaries. Allotted respite hours may be used at the discretion of the family within the eligibility period. Unused hours from a particular eligibility period are forfeited at the end of that period and cannot be carried forward into the next eligibility period.

Beneficiaries receiving services through any of the following publicly funded programs and benefits are not eligible for the CSHCS Respite benefit:

* Private Duty Nursing Benefit

* Children’s Waiver

* Habilitation Supports Waiver

* MI Choice Waiver

Requests for respite must be made in writing to MDHHS (refer to the Directory Appendix for contact information) and include
the following information:

* The health care needs of the beneficiary;

* The family situation that influences the need for respite; and

* Other community resources or support systems that are available to the family (e.g., CMH services, MDHHS services, adoption subsidy, SSI, trust funds, etc.).

MDHHS responds to all requests for respite in writing.

Electronic Bill Attachments - Basic requirments - WC claim and commercial

Electronic Bill Attachments

(a)Required reports and/or supporting documentation to support a bill as defined in Complete Bill Section 3.0 shall be submitted in accordance with this section. Unless otherwise agreed by the parties, all attachments to support an electronically submitted bill must either have a header or attached cover sheet that provides the following information:

(1)Claims Administrator - the name shall be the same as populated in the 005010X222, 005010X223, or 005010X224. Loop 2010BB, NM103.

(2)Employer - the name shall be the same as populated in the 005010X222, 005010X223, or 005010X224, Loop 2010BA, NM103.

(3)Unique Attachment Indicator Number - the Unique Attachment Indicator Number shall be the same as populated in the 005010X222, 005010X223, or 005010X224, Loop 2300, PWK Segment: Report Type Code, the Report Transmission Code, Attachment Control Qualifier (AC) and the unique Attachment Control Number. It is the combination of these data elements that will allow a claims administrator to appropriately match the incoming attachment to the electronic medical bill. Refer to the Companion Guide Chapter 2 for information regarding the Unique Attachment Indicator Number Code Sets.

(4)Billing Provider NPI Number – the number must be the same as populated in Loop 2010AA, NM109. If the provider is ineligible for an NPI, then this number is the provider?s atypical billing provider ID. This number must be the same as populated in Loop 2010AA, REF02.

(5)Billing Provider Name.

(6)Bill Transaction Identification Number – This shall be the same number as populated in the ASC 005010X222, 005010X223, or 005010X224 transactions, Loop 2300 Claim Information, CLM01.

(7)Document type – use Report Type codes as set forth in Appendix C of the Companion Guides.

(8)Page Number/Number of Pages the page numbers reported should include the cover sheet.

(9)Contact Name/Phone Number including area code.

(b)All attachments to support an electronically submitted bill shall contain the following information in the body of the attachment or on an attached cover sheet:

(1)Patient?s name

(2)Claims Administrator?s name

(3)Date of Service

(4)Date of Injury

(5)Social Security number (if available)

(6)Claim number (if available)

(7)Unique Attachment Indicator Number

(c)All attachment submissions shall comply with the rules set forth in Section One – 3.0 Complete Bills and Section Three – Security Rules. They shall be submitted according to the protocols specified in the Companion Guide Chapter 8 or other mutually agreed upon methods.
(d)Attachment submission methods:


(2)Electronic submission – if submitting electronically, the Division strongly recommends using the ASC X12N/005010X210 Additional Information to Support a Health Care Claim or Encounter (275) transaction set. Specifications for this transaction set are found in the Companion Guide Chapter 8. The Division is not mandating the use of this transaction set. Other methods of transmission may be mutually agreed upon by the parties.

(3)E-mail – must be encrypted

(e)Attachment types

(2)Supporting Documentation
(3)Written Authorization
(4)Misc. (other type of attachment)

Guidelines for submitting attachments, and corrected and secondary claims

Electronic claims with attachments To submit electronic claims with attachments, including high-dollar itemized claims:

› In the 837: Loop 2300 PWK (paperwork) segment of the claim, and indicate that notes will be faxed or mailed. (Do not put the actual notes in the segment.)

› Include in the notes:
– Patient name – Total amount billed
– Patient Cigna ID – Health care professional
– Date of birth – Taxpayer Identification Number (TIN)

Corrected claims submission

› In the Claim Frequency Type Code in Loop 2300, Segment CLM05, specify the frequency of the claim. (This is the third position of the Uniform Billing Claim Form Bill Type.)

› Use one of these codes:

1 – Original (admit through discharge claim)

7 – Replacement (replacement of prior claim)

8 – Void (void or cancel of prior claim)

Secondary claims submission
Secondary claims should be submitted to Cigna electronically. COB information is billed in Loops 2320 and 2330 on the electronic claim form. For further information, check with your EDI vendor.

Submitting via web portal - Additional information

As an Amerigroup provider, you can now send up to 10 unsolicited attachments through the web portal. You may submit up to 10 attachments for each claim, with a maximum file size of 10MB per attachment. This service includes attachments for secondary claims, or even attachments that are not related to a claim at all. Availity rejects any individual files larger than 10MB and requests that you split larger files into smaller files. Files can be submitted as TIFFs (.tif), JPEGs (.jpg), and PDFs (.pdf). This new feature allows your team to submit supporting
medical documentation for claims without prompting by Amerigroup.

CPT 81401, 81405, 81408, 81410, 81411 - Genetic Testing for Marfan Syndrome

Coding  Code Description CPT

81401 MED12 (mediator complex subunit 12)(eg, FG syndrome type 1, Lujan syndrome), common variants (eg, R961W, N1007S)

81405 ACTA2 (actin, alpha 2, smooth muscle, aorta) (eg, thoracic aortic aneurysms and aortic dissections), full gene sequence TGFBR1 (transforming growth factor, beta receptor 1) (eg, Marfan syndrome), full gene sequence

81408 FBN1 (fibrillin 1) (eg, Marfan syndrome), full gene sequence 
MYH11 (myosin, heavy chain 11, smooth muscle) (eg, thoracic aortic aneurysms and aortic dissections), full gene sequence

81410 Aortic dysfunction or dilation (eg, Marfan syndrome, Loeys Dietz syndrome, EhlersDanlos syndrome type IV, arterial tortuosity syndrome); genomic sequence analysis panel, must include sequencing of at least 9 genes, including FBN1, TGFBR1, TGFBR2, COL3A1, MYH11, ACTA2, SLC2A10, SMAD3, and MYLK

81411 Aortic dysfunction or dilation (eg, Marfan syndrome, Loeys Dietz syndrome, Ehler Danlos syndrome type IV, arterial tortuosity syndrome); duplication/deletion analysis panel, must include analyses for TGFBR1, TGFBR2, MYH11, and COL3A1

Genetic Testing for Marfan Syndrome, Thoracic Aortic Aneurysms and Dissections, and Related Disorders


Connective tissue is one kind of tissue that is found in the body. It connects and provides support to other tissues such as muscles, nerves, and the skin. For example, fat, bone and cartilage are types of connective tissues. Some problems with connective tissue can be inherited. This policy describes when it may be medically necessary to do genetic testing to look for inherited connective tissue disorders. 

Note:   The Introduction section is for your general knowledge and is not to be taken as policy coverage criteria. The rest of the policy uses specific words and concepts familiar to medical professionals. It is intended for providers. A provider can be a person, such as a doctor, nurse, psychologist, or dentist. A provider also can be a place where medical care is given, like a hospital, clinic, or lab. This policy informs them about when a service may be covered. 
Policy Coverage Criteria 

Testing Medical Necessity

Individual genetic testing for the diagnosis of Marfan
Individual genetic testing for the diagnosis of Marfan syndrome, other syndromes associated with thoracic aortic

Testing Medical Necessity

syndrome aneurysms and dissections, and related disorders, and panels comprised entirely of focused genetic testing limited to the following genes*FBN1 and MYH11 and ACTA2, TGFBR1, and TGFBR2 may be considered medically necessary when: * Signs and symptoms of a connective tissue disorder are Individual, targeted familial variant testing for Marfan syndrome

present, but a definitive diagnosis cannot be made using established clinical diagnostic criteria.
Individual, targeted familial variant testing for Marfan syndrome, other syndromes associated with thoracic aortic aneurysms and dissections, and related disorders, for assessing future risk of disease in an asymptomatic individual, may be considered medically necessary when there is a known pathogenic variant in the family. (See Additional Information section below)
Testing Investigational
Genetic testing panels for Marfan syndrome

Additional Information

Genetic testing panels for Marfan syndrome, other syndromes associated with thoracic aortic aneurysms and dissections, and related disorders that are not limited to focused genetic testing that do not meet the criteria for limited focused gene variant testing described above are considered investigational. (See Additional Information section below)

* Tissues that surround organs, blood vessels, and bones are called connective tissue. Changes to certain genes may cause problems with connective tissue. Specific genes can be tested to diagnose connective tissue problems. 

* Syndromes associated with thoracic aortic aneurysms may have established clinical criteria with major and minor criteria, eg, Marfan syndrome (Ghent criteria) and Ehlers-Danlos syndrome type IV, or may be associated with characteristic clinical findings. While most of these syndromes can be diagnosed based on clinical findings, these syndromes may be associated with variability in clinical presentation and may show overlapping features with each other, and with other disorders. The use of genetic testing to establish a diagnosis in a patient with a suspected connective tissue disorder is most useful in those patients who do not meet sufficient clinical diagnostic criteria at the time of initial examination, in patients who have an atypical phenotype and other connective tissue disorders cannot be ruled out, and in individuals who belong to a family in which a pathogenic variant is known (presymptomatic diagnosis).

* Genetic testing has conventionally been used when a definitive diagnosis of one of these syndromes cannot be made. More recently, panels using next-generation sequencing (NGS), which test for multiple genes simultaneously, have been developed for the syndromes associated with thoracic aortic aneurysms and dissections, and other conditions that may have overlapping phenotypes. Although the laboratory-reported sensitivity is high for some of the conditions on the panel, the analytic validity of these panels is unknown, and detection rates of variants of uncertain significance are unknown.

* However, there may be certain clinical scenarios in which focused panel testing may be appropriate to include a narrow list of differential diagnoses of thoracic aortic aneurysms and dissection based on clinical findings.

Panel Testing

Specific CPT codes for genetic panel tests associated with aortic dysfunction or dilation syndromes (81410 and 81411) are described in the coding table above with the genes included in each test.

Related Information 

Genetics Nomenclature Update

The Human Genome Variation Society nomenclature is used to report information on variants found in DNA and serves as an international standard in DNA diagnostics (see Table 2). The Society’s nomenclature is recommended by the Human Variome Project, the HUman Genome Organization, and by the Human Genome Variation Society itself.

The American College of Medical Genetics and Genomics and the Association for Molecular Pathology standards and guidelines for interpretation of sequence variants represent expert opinion from both organizations, in addition to the College of American Pathologists. These recommendations primarily apply to genetic tests used in clinical laboratories, including genotyping, single genes, panels, exomes, and genomes. Table 3 shows the recommended standard terminology—“pathogenic,” “likely pathogenic,” “uncertain significance,” “likely benign,” and “benign”—to describe variants identified that cause Mendelian disorders.

Table 2. Nomenclature to Report on Variants Found in DNA

Previous  Updated  Definition
Mutation Disease-associated variant Disease-associated change in the DNA sequence
 Variant Change in the DNA sequence 
 Familial variant Disease-associated variant identified in a proband for use in subsequent targeted genetic testing in first-degree relatives

ACMG-AMP Standards and Guidelines for Variant Classification

Previous  Definition

Pathogenic Disease-causing change in the DNA sequence
Likely pathogenic Likely disease-causing change in the DNA sequence 
Variant of uncertain significance Change in DNA sequence with uncertain effects on disease
Likely benign Likely benign change in the DNA sequence
Benign Benign change in the DNA sequence
American College of Medical Genetics and Genomics; AMP: Association for Molecular Pathology.

Genetic Counseling

Genetic counseling is primarily aimed at patients who are at risk for inherited disorders, and experts recommend formal genetic counseling in most cases when genetic testing for an inherited condition is considered. The interpretation of the results of genetic tests and the understanding of risk factors can be very difficult and complex. Therefore, genetic counseling will assist individuals in understanding the possible benefits and harms of genetic testing, including the possible impact of the information on the individual’s family. Genetic counseling may alter the utilization of genetic testing substantially and may reduce inappropriate testing. Genetic counseling should be performed by an individual with experience and expertise in genetic medicine and genetic testing methods.

Question: Claims processing for CPT Codes 81401-82408 when ICD-9s have been identified for coverage. The structure of these codes raises some practical considerations for claims submission and processing. The molecular pathology codes have a number of subparts, identified by specific genes. This means there could be a number of genes reported with the same CPT code. Each of those genes could have related ICD-9 codes. It would require reporting of the specific gene to be able to link the code with a diagnosis. In this draft coverage policy, 4 of the codes [81401, 81403, 81405, and 81406] have been associated with testing for Lynch Syndrome and would be covered for specific diagnosis codes. However, there are many genes under those same codes and other conditions that would be covered, e.g. lymphoma, leukemia which
are covered conditions (NCD §190.3).

Will claims for other gene testing reported under the same codes be denied because they do not have the ICD-9 for Lynch Syndrome? How are we to report testing for other genes and conditions reported under the same CPT code, so that they are not all inappropriately denied?

Response: These CPT codes are not gene specific and can be used for multiple tests. The higher level CPT codes are noted in the LCD to let providers know they are covered for the conditions listed in the policy. All other conditions are subject to the test being reasonable and medically necessary. We will request additional documentation for conditions or diseases that are not listed in the LCD for 81401, 81403, 81405 and 81406

Documentation Guidelines

Documentation must be adequate to verify that coverage guidelines listed above have been met. Thus, the medical record must contain documentation that the testing is expected to influence treatment of the condition toward which the testing is directed. The laboratory or billing provider must have on file the physician requisition which sets forth the diagnosis or condition that warrants the test(s). Examples of documentation requirements of the ordering physician/nonphysician practitioner (NPP) include, but are not limited to, history and physical or exam findings that support the decision making, problems/diagnoses, relevant data (e.g., lab testing, imaging results).

Documentation requirements of the performing laboratory (when requested) include, but are not limited to, lab accreditation, test requisition, test record/procedures, reports (preliminary and final), and quality control record. Documentation requirements for lab developed tests/protocols (when requested) include diagnostic test/assay, lab/manufacturer, names of comparable assays/services (if relevant), description of assay, analytical validity evidence, clinical validity evidence, and clinical utility.

Providers are required to code to specificity however, if an unlisted CPT code is used the documentation must clearly identify the unique procedure performed. When multiple procedure codes are submitted on a claim (unique and/or unlisted) the documentation supporting each code should be easily identifiable. If on review the contractor cannot link a billed code to the documentation, these services will be denied based on Title XVIII of the Social Security Act,

When the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary under Section 1862(a)(1)(A) of the Social Security Act.

Many applications of the molecular pathology procedures are not covered services given lack of benefit category (preventive service) and/or failure to reach the reasonable and necessary threshold for coverage (based on quality of clinical evidence and strength of recommendation). Furthermore, payment of claims in the past (based on stacking codes) or in the future (based on the new code series) is not a statement of coverage since the service was not audited for compliance with program requirements and documentation supporting the reasonable and necessary testing for the beneficiary. Certain tests and procedures may be subject to prepayment medical review (records requested) and paid claims must be supportable, if selected, for post payment audit by the MAC or other contractors. Tests for diseases or conditions that manifest severe signs or symptoms in newborns and in early childhood or that result in early death (e.g., Canavan disease) could be subject to automatic denials since these tests are not usually relevant to a Medicare beneficiary.

Submittig more than 12 ICD and supplemental DX code

The Centers for Medicare & Medicaid Services (CMS) requires all health plans to submit Health Insurance Portability and Accountability Act (HIPAA)-compliant 837 claims transactions to CMS for Medicare risk adjustment.

Chart review submissions

Electronic transactions related to chart reviews (i.e., resulting from the review of a medical chart) should be identified as such on all HIPAA-compliant 837 transactions.

• Code changes are important for proper reporting and reimbursement of transactions related to chart reviews.
• Proper identification of encounter data chart reviews is important because the CMS timely filing period is longer for chart review encounters (approximately 25 months from the date of service) than for original, or full, encounters (13 months from the date of service).

Please be aware of the following changes when submitting electronic transactions to CarePlus:

•    On encounters generated from a chart review, please submit your HIPAA-compliant 837 transactions with the following values:

*    LOOP 2300
i.    CLM02 = 0
ii.    PWK01 = 09
iii.    PWK02 = AA
o    LOOP 2400
i.    SV101-2 = 99499
ii.    SV102 = 0
iii.    SV101-7 = CR
•    Any diagnosis identified during the chart review also should be submitted on the HIPAA-compliant 837 transaction in the following loop and segment:
o    LOOP 2300
i.    HI01 – HI12 (as needed)

Additional diagnosis codes

CarePlus provides a supplemental Current Procedural Terminology (CPT®) code to assist in reporting additional diagnosis codes for risk adjustment because of practice management system or clearinghouse limitations.

• The supplemental CPT code is intended as a placeholder for additional diagnosis codes exceeding the fourth diagnosis pointer.

• The supplemental code should contain a $0.01 charge to ensure appropriate claim processing; however, there will be no additional reimbursement.

Please be aware of the following changes when submitting electronic transactions to CarePlus:

•    On encounters generated from office visits, please submit your HIPAA-compliant 837 transactions with the following values:
*    LOOP 2400
i.    SV101-2 = 99499
ii.    SV102 = .01
•    Any diagnosis identified during the office visit also should be submitted on the HIPAA-compliant 837 transaction in the following loop and segment:
o    LOOP 2300
i.    HI01 – HI12 (as needed)

Slide notes for submitting more than 19 ICD codes - No fault and worker compensation claims

There  may be times when a beneficiary is severely injured and the RRE has more than 19 ICD diagnosis codes to  report.

Since the Claim Input File Detail Record only has room for 19 ICD diagnosis codes, it is important that an RRE  reports at least one ICD diagnosis code for each injured body part.

In such a situation, it is likely that a number of the diagnosis codes relate to the same body part.  For example,  multiple diagnosis codes could be listed when a back injury occurs.

When there are more than 19 diagnosis  codes, be sure to report at least one diagnosis code for each body part  that was injured.  Eliminate diagnosis codes that refer to a previously reported body part.

submitting more than 12 ICDs example

Submitting more than 12 ICD by claim level

• Diagnoses should be reported in form locator field (FL) 66- 67 a-q on the CMS-1450 claim form. Up to 12 diagnoses can be reported in item 21 on the CMS-1500 paper claim (02/12) (see the 2015 PQRS Implementation Guide) and up to 12 diagnoses can be reported in the header on the electronic claim.

Only one diagnosis can be linked to each line item.

PQRS analyzes claims data using ALL diagnoses from the base claim (item 21 of the  CMS-1500 or electronic equivalent) and service codes for each individual EP (identified by individual NPI).

EPs should review ALL diagnosis and encounter codes listed on the claim to make sure they are capturing ALL measures chosen to report that are applicable to the patient's care.

• All diagnoses reported on the base claim will be included in PQRS  analysis, as some measures require  reporting more than one diagnosis on a claim. 

For line items containing QDC, only one diagnosis from the base claim should be  referenced  in the diagnosis pointer field.

To report a QDC for a measure that requires reporting of multiple diagnoses, enter the reference number in the diagnosis pointer field that corresponds to one of the measure’s diagnoses listed on the base claim. Regardless of the reference number in the diagnosis pointer field, all diagnoses on the claim(s) are considered in PQRS analysis. (See 2015 PQRS Implementation Guide)

• If your billing software limits the number of line items available on a claim, you must add a $0.01 nominal amount to one of the line items on that second claim for a total charge of one penny. 

PQRS analysis will subsequently join the claims based on the same beneficiary for the same date-of-service, for the same TIN/NPI and analyzed
as one claim.

Providers should work with their billing software vendor/clearinghouse regarding line limitations for claims to ensure that diagnoses, QDCs, or nominal charge amounts are not dropped.

In an effort to streamline reporting of QDCs across multiple CMS quality reporting programs, CMS strongly encourages all EPs and practices to begin billing 2015 QDCs with a $0.01 charge. EPs should pursue updating their billing software to accept the $0.01 charge prior to implementing 2015 PQRS. EPs and practices need to work with their billing software or  EHR vendor to ensure that this capability is activated.

CSHCS - Covered Benifits, renewal of coverage


CSHCS covers services that are medically necessary, related to the beneficiary’s qualifying diagnosis(es), and ordered by the beneficiary’s CSHCS authorized specialist(s) or subspecialist(s). Services are covered and reimbursed according to Medicaid policy unless otherwise stated in this chapter.

The primary CSHCS benefits may include:

* Ambulance

* Care Coordination*

* Case Management*

* Dental (Specialty and General)

* Dietary Formulas (limited)

* Durable Medical Equipment (DME)

* Emergency Department (ED)

* Hearing and Hearing Aids

* Home Health (intermittent visits)

* Hospice*

* Hospital at approved sites (Inpatient/Outpatient)

* Laboratory Tests

* Medical Supplies

* Monitoring Devices (Nonroutine)

* Office Visits to CSHCS Authorized Physicians

* Orthopedic Shoes

* Orthotics and Prosthetics

* Parenteral Nutrition

* Pharmacy

* Physical/Occupational/Speech Therapy

* Radiological Procedures

* Respite*

* Telemedicine

* Transplants and Implants

* Vision

(* Refer to the information and authorization requirements stated in this Section.)


If a beneficiary enters or leaves a facility that is not a covered facility (e.g., nursing facility, or intermediate care facility) during a month of eligibility, the beneficiary remains a beneficiary for the remainder of that month. However, services provided to the beneficiary while in the facility are not covered (i.e., reimbursable) by CSHCS as these facilities are responsible for providing the medical care. (Refer to the General Information for Providers Chapter in this manual for additional information for beneficiaries who also have Medicaid coverage.)


The beneficiary’s coverage may be renewed as needed if all eligibility criteria continue to be met and thefamily completes the renewal process. Medical review reports are required according to the timeframes  established based on the primary diagnosis for the beneficiary. An annual financial review is also required. If all of the criteria continue to be met for CSHCS coverage, a new coverage period is typically issued in 12-month increments.

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