Effective Date: January 1, 2021

Purpose:

This policy provides reimbursement guidelines for HCPCS code T2046 for hospice room and board.

Scope:

Product included:

• NJ FamilyCare/Medicaid Plan

Definitions:

• T2046: Hospice long-term care, room and board only; per diem

Policy:

For members who reside in a long term care facility who are now receiving hospice room and board services from an individual hospice agency, the hospice room and board claims will be paid at 95% of the long term care facility’s Medicaid custodial per diem rate. The hospice room and board claim must be billed by the individual hospice agency with HCPCS level II code T2046.

For members who resides in a Specialty Care Nursing Facility (SCNF) who are now receiving hospice room and board services from an individual hospice agency, the claims will be paid at 95% of the SCNF Medicaid per diem rate. The hospice room and board claim must be billed by the individual hospice agency with HCPCS level II code T2046.

T2046 is calculated at 95% of the Medicaid long term care facility per diem rate effective at the time services are provided, and excluding retroactive rate adjustments, retroactive add-ons and special program rates for private and county long term care facilities.

Procedure:

Horizon NJ Health will consider for reimbursement HCPCS level II code T2046 at 95% of the Medicaid long term care facility custodial per diem rate for hospice room and board.

Horizon NJ Health will consider for reimbursement HCPCS level II code T2046 at 95% of the SCNF Medicaid per diem rate for hospice room and board.

References:

Human Services, DMAHS, “Hospice Services Manual”
https://www.state.nj.us/humanservices/providers/rulefees/ruleadop/ruleadoptfiles/(F)%20R.2016%20d.007%20(DHS-DMAHS%2010_53A).pdf

American Medical Association, Current Procedural Terminology (CPT®) and associated publications and services

Limitations and Exclusions:

Notwithstanding the foregoing, all payment determinations are subject to all other, applicable limitations, including but not limited to, the following:

• Benefit limitations;
• The terms of any applicable provider participation agreement;
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
• Medical necessity; and
• Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.

CPT Copyright 2017 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. The CPT codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.