HCPCS code S0255 – Hepatitis B vaccine billing guide

Key takeaways

HCPCS Code S0255 reports a hospice referral visit by a nurse, social worker, or other designated staff. The visit advises the patient and family of care options.

S0255 is a temporary national S-code, and CMS lists it as not payable by Medicare, so Original Medicare claims will not pay.

Medicaid programs and commercial plans decide for themselves whether to recognize S0255 and what to pay, because no national fee schedule exists.

A physician’s pre-election hospice evaluation is a different service, reported with G0337, and advance care planning by a practitioner uses CPT 99497 and 99498.

The visit note should show who performed the visit, which care options were discussed, who attended, and how long it took.

HCPCS Code S0255: Official descriptor and code definition

HCPCS Code S0255 reports a hospice referral visit that advises the patient and family of care options. A nurse, social worker, or other designated staff member performs it. It is a temporary national S-code, used by private payers and Medicaid programs for services with no other national code. The Centers for Medicare and Medicaid Services (CMS) publishes it in the HCPCS Level II file, and Original Medicare does not pay it.

The official long descriptor reads: Hospice referral visit (advising patient and family of care options) performed by nurse, social worker, or other designated staff. The short descriptor is “Hospice refer visit nonmd”, which flags that the code is meant for staff other than a physician.

What S0255 covers and what it excludes

S0255 describes an informational visit that comes before a hospice election. A nurse, social worker, or other staff member explains hospice and other care options to the patient and family. No treatment happens at the visit. Its purpose is to help the family reach an informed decision.

The descriptor sets clear limits on who performs the visit and what it includes. Read it against the visit you are about to bill.

• Covered: a referral visit where designated staff advise the patient and family about hospice and related care options.
• Performed by: a nurse, social worker, or other staff the payer or program designates. The code is not written for a physician visit.
• Not covered by S0255: a physician’s pre-election hospice evaluation and counseling, which is reported with G0337.
• Not covered by S0255: hospice care itself. Routine home care, respite care, and general inpatient care have their own codes.
• Not covered by S0255: advance care planning by a physician or other qualified practitioner, which uses CPT 99497 and 99498.

Which payers accept HCPCS Code S0255?

Medicaid programs and commercial plans may accept S0255, but Original Medicare does not pay it. The S-series is a set of temporary national codes for non-Medicare use, so each payer chooses whether to recognize it. Confirm acceptance with the specific plan before the visit.

Medicare coverage status for S0255

The HCPCS file assigns S0255 coverage code I, which means not payable by Medicare. Billing S0255 to a Medicare administrative contractor will not produce a payment. When a physician employed by the hospice performs a pre-election evaluation, the hospice reports G0337 under Medicare’s hospice benefit instead.

Reimbursement rates and fee schedule guidance for S0255

S0255 has no national fee schedule amount. Its Medicare pricing indicator is 00, and it does not appear on the CMS Physician Fee Schedule. Every rate you see comes from a payer’s own schedule or contract.

• State Medicaid: search your state’s current fee schedule for S0255. If the code is absent, the state does not recognize it.
• Managed care plans: rates may match the state Medicaid rate or follow a separate contracted rate.
• Commercial payers: payment is contractual. Check your fee schedule addendum or ask provider relations.
• Units: the descriptor describes a visit, so most payers expect one unit per visit. Confirm the unit definition before you bill more than one.

Documentation payers expect for S0255

The record has to show that a referral visit took place and what it covered. Payers that recognize S0255 review the note against the descriptor, so write it with that test in mind.

• Visit date and location: where the visit took place, such as the home, an office, or a facility.
• Who performed it: the staff member’s name, role, and credentials, such as RN or licensed social worker.
• Who attended: the patient, family members, or a legal representative.
• What was discussed: the care options explained, including hospice eligibility, the services hospice provides, and alternatives.
• The referral source: the physician or practitioner who requested the visit, if the payer requires an order.
• Outcome and next steps: whether the family wants a hospice evaluation, needs more time, or declined.
• Prior authorization: the authorization number, if the payer required one before the visit.

ICD-10-CM diagnosis codes commonly paired with S0255

The primary diagnosis is usually the serious or terminal condition that prompted the referral. Supporting codes can add context. Confirm current code status in the CDC/NCHS ICD-10-CM tool before you submit.

Modifiers and place of service for S0255

No national modifier rules apply to S0255. Some Medicaid programs ask for a modifier that identifies the staff type. Examples are TD for a registered nurse and AJ for a clinical social worker. Use only the modifiers the payer’s billing guide lists.

Report the place of service code that matches where the visit happened. For example, use 12 for the patient’s home or 11 for an office.

Related and easily confused codes

Hospice and end-of-life services sit across several code sets. Choosing between them depends on who performed the service, whether hospice has been elected, and which payer you are billing. The first two questions settle most cases.

When a physician or other qualified practitioner leads the discussion, the 99497 guide explains how advance care planning is billed. Once hospice is elected, physician oversight of the care plan moves to G0182.

The AAPC HCPCS code lookup lets you confirm a descriptor before you submit.

Common claim denial reasons for S0255 and how to fix them

Most S0255 denials trace back to payer recognition or a mismatch with the descriptor. Good denial management strategies start with the remark code on each remittance, so you fix the cause. Our reference on medical billing denial codes defines each CARC in the table below.

How to bill S0255, step by step

The workflow below keeps the claim aligned with the descriptor and the payer’s rules. Pair it with the clean claim submission guidelines for the fields every claim needs.

1. Confirm the payer recognizes S0255. Check the state Medicaid code list or the commercial contract. Stop if the patient has only Original Medicare.
2. Check hospice election status. A referral visit belongs before election, not after it.
3. Get prior authorization if required. Record the number before the visit.
4. Document the visit. Note the performer, attendees, care options discussed, and the outcome.
5. Code the claim. Enter S0255 with the condition code first, the place of service, and any payer-required modifier.
6. Submit and track. Watch the remittance and correct any denial against its remark code.

How Pabau supports S0255 documentation and claims

A hospice referral visit involves several people and a sensitive conversation. Pabau, our documentation and billing platform for practices, keeps the visit note, the authorization, and the claim on one patient record.

Pabau’s digital forms let your nurse or social worker record who attended, which options were discussed, and what the family decided. Pabau’s claims management software submits the claim and tracks its status and remittance.

Your billing team sees which payers paid S0255 and which denied it, without switching tools. That supports wider revenue cycle management across your S-code and CPT claims.

Keep hospice referral visits documented and billed

Pabau holds the visit note, the authorization, and the claim on one patient record. Your team can see which payers paid S0255 and which ones denied it.

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Conclusion

S0255 pays only where a payer has chosen to recognize it, so its value depends on your payer mix more than on the visit itself. Original Medicare will not pay it under any documentation.

Timing is the trade-off worth remembering. Election status and prior authorization have to be settled before the visit, because neither can be fixed once the claim goes out. When a physician leads the conversation, G0337 or the advance care planning codes fit better.

Book a demo to see how Pabau links the referral visit note to the claim and its payment.

Continue your research

Need a denial management framework? Denial management in healthcare covers how to categorize, appeal, and prevent the most common claim denials across payer types.

Want to understand the full revenue cycle? Revenue cycle management explained breaks down each stage from eligibility check to payment posting.

Looking for a clean claim checklist? Clean claim submission guidelines outlines every required field and common scrubbing checks before a claim is transmitted.

Billing hospice care after election? T2042 covers the Medicaid per diem for hospice routine home care.

Frequently asked questions