Palmetto GBA Hospice Coalition Questions and Answers

Transcription

1 Palmetto GBA Hospice Coalition Questions and Answers September 23, 2008

2 To: Hospice Coalition Members From: Palmetto GBA Provider Education Date: September 23, 2008 Location: Palmetto GBA Attachment A: Attachment B: Attachment C: Attachment D: Palm Harbor Migration Article Hospice CAP Results PEACE Project Summary Appeals Report NOTE: Ed Greenleaf is the new director of Appeals, Provider Contact Center and Provider Outreach and Education. Discharges 1. MedLearn Matters MM6115 released July 18, 2008 provides the following information: Section of the Code of Federal Regulations (CFR) provides discharge instructions for hospices, including for those extraordinary circumstances in which a hospice may be required to discharge a patient for cause from its services, including causes such as where patient safety or hospice staff safety is compromised. Currently, discharge for cause is not identified on the Medicare claim. In order to identify these discharges, the Centers for Medicare & Medicaid Services (CMS) asked the National Uniform Billing Committee (NUBC) to approve a new condition code. This new code (H2) is to be used for claims with dates of service on or after January 1, 2009 as appropriate, to indicate that the patient meets the hospice s documented policy addressing discharges for cause. Please note that this results only in a discharge from the provider s care, not from the Medicare hospice benefit. Can Palmetto GBA interpret and give us guidance on the last sentence in the above paragraph? If a patient is discharged for cause, how do they not become discharged from the Medicare hospice benefit? Who is in charge of their care if they are not discharged from the benefit but from a providers care? If another hospice picks up the patient, does a new benefit period start or does the patient remain in the same benefit period as when discharged for cause? September 23, 2008 Hospice Coalition Meeting 1

3 The MedLearn Matters MM6115, released on July 18, 2008, which is taken from Change Request (CR) 6115, instructs providers to enter condition code H2 on claims with dates of service on or after January 1, 2009, to indicate when a patient was discharged for cause. CMS has clarified that the statement in the CR, which reads, Discharge for cause identifies a discharge from the provider s care, not from the Medicare hospice benefit, was intended as an addition to the patient status code, which in the case of a discharge for cause, could be discharged to home. The reporting of this code does not change the current processes with regard to discharge or transfer. In essence, as stated in CR 6115, hospices are required to enter the H2 condition code on claims for dates of service on or after January 1, 2009, for patients who were discharged for cause. However, the requirement to submit the 42 occurrence code and date will not change. 2. Can a hospice ever discharge a patient for cause when the patient is hospitalized outside the plan of care? As stated in, the Code of Federal Regulations (42 CFR ) a hospice may discharge a patient if the hospice determines, under a policy set by the hospice for the purpose of addressing discharge for cause and complies with the requirements noted in (a) (3) (i) through (a) (3) (iv). Depending upon the reason why the patient was hospitalized outside the plan of care, an agency would need to determine if the situation falls under these requirements. If a patient went into the hospital for something related to the terminal illness without having the hospice arrange the hospital stay, the hospice cannot discharge for cause. However, if the hospice followed procedure and informed the patient about the requirement for all care to be arranged through the hospice, the patient may be held liable for payment. 3. Can you provide background for CR6115 regarding the new code required on claim forms for discharge for cause? How will Palmetto GBA be using this new data in claims processing? In medical review? As stated in CR 6115 Currently, discharge for cause is not identified on the Medicare claim. In order to identify these discharges, CMS requested the National Uniform Billing Committee (NUBC) approve a new code. On May 21, 2008 the NUBC approved condition code H2 to be effective January 1, For claims with dates of service on or after January 1, 2009, hospices shall report the condition code H2 on claims when Medicare beneficiaries are discharged for cause according to the hospice s documented policy addressing discharges for cause. Discharge for cause identifies a discharge from the provider s care, not from the Medicare hospice benefit. September 23, 2008 Hospice Coalition Meeting 2

4 In addition, the business requirements of CR 6115 instruct Medicare systems to accept the new condition code H2. The CMS has not provided any other instructions to Palmetto GBA with regard to the use of this code. 4. Some hospitals in some communities are refusing to contract with any hospices. The patient has no choice but to revoke if they choose to seek inpatient care at that hospital. Can Palmetto GBA provide guidance in these situations? A contract should be obtained with local hospitals for hospice patients. Details of the contract can be found in the CMS Internet Only Manual Publication , Chapter 11, Section 60.1 at Beneficiaries should be notified upon admission to the hospice which hospitals the hospice obtained a contract from and the possibility of patient financial liability for care outside of the contracted facilities for care related to the terminal diagnosis. It is the responsibility of the patient to seek medical care from those contracted hospitals after seeking preapproval from the hospice agency. If a contract can not be obtained by the hospice agency at a hospital, the beneficiary can choose to revoke the Hospice Medicare Benefit and enter into a non contracted facility. 5. The Palmetto GBA Hospice Coalition questions and answers for November 14, 2006 contained a question and answer related to the proper application of LCD criteria on decisions to discharge the patient. a. Q: A CHF patient meets all criteria on the LCD at the time of admission to hospice and at each recertification period continues to meet all the criteria as assessed by the physician. At what point do you determine that you need to discharge? If discharged, they will meet the criteria for eligibility for another hospice to admit. Is there a limit to the length of time your hospice can serve them when they continue to meet the LCD criteria? b. A: The decision to discharge a patient rests with the agency. If the agency determines that the patient is no longer appropriate for hospice care then a discharge would be appropriate. Decisions related to discharge should be based on the condition of the patient. Information to support this decision should be documented in the medical record. Decisions related to discharge should not be based on length of time on service but whether a patient meets the criteria for coverage under the hospice benefit. It is unclear as to why a hospice would be considering discharging a patient who continues to meet the LCD criteria. We understood this to mean that if the patient meets the LCD criteria at recertification and if the medical director continues to certify the patient as terminally ill with a medical prognosis of 6 months or less if the disease follows the normal course, that the patient is eligible to remain on hospice care with or without the presence of significant documented decline. Is our understanding correct? September 23, 2008 Hospice Coalition Meeting 3

5 As stated in the answer above from 2006, the decisions related to discharge (and for admission, for that matter) should be based on the condition of the patient, and the information to support this decision should be documented in the medical record. The LCDs for Hospice that have been published by Palmetto GBA have provided guidance in this, as illustrated by question 4 below under Medical Review. The physician and team assessing hospice appropriateness has LCDs now which discuss the ICF (International Classification of Functioning, Disability and Health) and how it can provide key pieces of data for determining hospice appropriateness. The decision support offered by this classification system supplies necessary documentation that can be incorporated into the medical record and will substantiate the reason that hospice is appropriate. There is no requirement that significant documented decline must be included in this discussion that is provided within the record. CR CMS has clarified that continuous care visits are counted in the same manner as routine home care visits. However a continuous care visit could be for 8 hours or more. This greatly increases the cost of the visit for the hospice, i.e. the cost is significantly higher than a routine visit. Is it acceptable to have a higher charge for the nursing and hospice aide visit for continuous care? Each facility should have an established charge structure which is applied uniformly to each patient as services are furnished to the patient and which is reasonably and consistently related to the cost of providing the services. While the Medicare program cannot dictate to a provider what its charges or charge structure may be, the program may determine whether or not the charges are allowable for use in apportioning costs under the program. Provider Reimbursement Manual Part 1, Chapter 22, Determination of Cost of Services Provider Charge Structure Section Will Palmetto GBA be using the claims data during medical review; i.e. will they be matching the visits submitted on the claim form to the visit notes submitted for medical review? What will the outcome to the provider if the visits do not match? This is a data collection activity and Medical Review has not been directed by CMS to match the visit notes to the visits submitted on the claim. 3. How should visits be counted in inpatient units? What criteria should be used to determine what constitutes a visit in an inpatient unit? According to Change Request 5567, CMS does not require hospices to report visit data at this time for visits made by non hospice staff providing General Inpatient Care in contracted facilities. However, General Inpatient Care visits related to the palliation and management of the terminal illness or related conditions provided by hospice staff in contracted facilities must be reported, and all General Inpatient Care visits related September 23, 2008 Hospice Coalition Meeting 4

6 to the palliation and management of the terminal illness or related conditions provided in hospice-owned facilities must be reported. For services provided on or after January 1, 2007, hospices must report a HCPCS code along with each level of care revenue code to identify the type of service location where that level of care was provided. These include inpatient facilities listed below: Q5005 HOSPICE CARE PROVIDED IN INPATIENT HOSPITAL Q5006 HOSPICE CARE PROVIDED IN INPATIENT HOSPICE FACILITY Q5008 HOSPICE CARE PROVIDED IN INPATIENT PSYCHIATRIC FACILITY CMS Publication , Change Request 5567, Transmittal 1494 Information on determining a visit can be found in the Medlearn Matters Article A service/visit constitutes direct care to the beneficiary. An entry in a medical record without a visit does not constitute a visit and as such is not counted. Rounds in facilities do not constitute a visit and as such are not counted. Items and services provided within a visit are not counted as separate items. 4. From Palmetto GBA s perspective, how did the implementation of CR 5567 go? From Palmetto GBA perspective, the implementation of CR 5567 seemed to go smoothly. We would be interested in knowing the number of bills per state and the percentage of returned bills. Palmetto GBA does not have reports in place to provide this information. Were there any technical denials? Please provide specifics on technical denials for research. Any tips that you could give us on further education to hospice providers? The perspective of the 2008 RHHI Hospice Workshop series participants seems to be that providers are comfortable with the implementation of CR5567 and the billing changes. September 23, 2008 Hospice Coalition Meeting 5

7 MAC 1. Please provide an update on the MAC process. The home health and hospice workload has also been split into four jurisdictions (see HH&H MAC Jurisdiction Map). CMS is not going to procure separate MACs to service home health and hospice providers. Instead, CMS will integrate these four jurisdictional claims workloads into the following four A/B MAC competitions: Jurisdiction 6 will include home health and hospice Jurisdiction D, Jurisdiction 11 will include home health and hospice Jurisdiction C, Jurisdiction 14 will include home health and hospice Jurisdiction A and Jurisdiction 15 will include home health and hospice Jurisdiction B. Information on the MAC process can be found at: A/B MAC Jurisdiction map: ons_map.pdf HH+H MAC Service Area map: An update on the MAC process will be provided during the meeting. 2. How will multi-state, multi-site hospice organizations be assigned to a MAC? An update on the MAC process will be provided during the meeting. Medical Review 1. Since we live in the era of evidence-based medical practice and have been advised that the case reviewers will be reviewing our hospice charts based on it, what are the references that show that the use of the International Classification of Function has been validated as a tool that will reliably predict a patient's prognosis of 6 months or less? The ICF (International Classification of Functioning, Disability and Health) is not a tool or instrument ; it is a classification system that provides a universal language for documenting and communicating an individual s health status. Hospice-specific tools and instruments may be created using the ICF. This level of information would help hospice providers paint the picture of any individual electing the Medicare hospice benefit, no matter the level of complexity. September 23, 2008 Hospice Coalition Meeting 6

8 Health status information, categorized in a systematic fashion, is of value in making both predictions (prognostications) and informed decisions. Previous sets of hospice eligibility criteria established both specific and non-specific criteria for hospice admission. Using the ICF allows for a more complete description of an individual s health status because both current and as yet unidentified associations between health status and six month prognosis can be described and reported in a comprehensive manner. On a population level, such information would allow for a comprehensive description of a hospices patient population and palliative outcomes. This information could of course include six-month prognosis, but could also include other critical palliative outcomes including adverse patient events. Collecting and organizing data using the concepts embodied by the ICF taxonomy would in the short-term help support clinical decisions, and in the long-term help address the administrative requirements impacting hospice providers. 2. While the ICF System may have some validity for usage in other patient populations or for the development of care planning, does Palmetto GBA have any plans to test the validity and/or usefulness of the ICF System regarding hospice appropriateness? Please see answer to question #1. The ICF taxonomy, together with the International Classification of Diseases (ICD), provides an excellent framework to describe functioning within categories of diseases, disorders and injuries. To the extent that there are core items in the ICF that are shared among individuals deemed to be hospice appropriate, the ICF would support such a study. This would, however, be outside the scope of Palmetto GBA s current business. 3. Please provide an update on Palmetto GBA s plans to expand ICF verbiage in LCD s that currently do not have them. At this time, the tentative decision is to revise the LCD for Hospice Stroke and Coma (L316) using the Going Beyond Diagnosis structure which incorporates the ICF into the documentation system for beneficiaries with stroke or coma. Our intent is to provide an opportunity to providers to better identify, document and communicate the unique health care needs of individuals whose combined effects of their stroke or coma along with any other identified comorbid condition(s) should be such that most would have a prognosis of six months or less. Again, as in the other LCDs so modified, the use of the ICF to help identify and document the unique service needs of these beneficiaries with stroke or coma would be suggested, but not required. September 23, 2008 Hospice Coalition Meeting 7

9 4. Palmetto GBA s recent re-drafting of several LCDs to incorporate the ICF has resulted in the disappearance of virtually all measurable criteria. At a recent Palmetto GBA training we were told that patients who meet the former (more measurable) LCDs would certainly qualify under the new ICF-driven LCDs and that, therefore, hospices may choose to continue to use the former LCDs if they wish. We plan to continue to use the former LCDs in addition to incorporating the ICF in our practice. In the future, if a patient meets the measurable requirements of the former LCDs are we correct that the patients will be considered eligible under the Medicare hospice benefit? The specific eligibility criteria contained in previous versions of Palmetto GBA Hospice LCDs had to be supplemented by non-specific criteria (e.g., rapid decline or comorbidity ) to ensure that the LCDs, once implemented, did not inappropriately exclude hospice eligible individuals from the Medicare benefit. While the specific criteria were generally incorporated into hospices admission worksheets, Palmetto GBA s review of medical records indicated that many individuals with non-cancer conditions, were being admitted based not on the specific eligibility criteria, but rather on the non-specific criteria such as rapid decline or comorbidity. In order to provide a more comprehensive framework for both the specific and nonspecific criteria, Palmetto GBA incorporated the ICF concepts into the revised Hospice LCDs. As written, the revised Hospice LCDs for Renal Care, ALS, and Cardiopulmonary Conditions would support the usage of the previously established specific eligibility criteria, plus provide a model for the incorporation of relevant secondary and comorbid conditions, which are often the root cause of the previously noted rapid decline. Going Beyond Diagnosis articles found on the Palmetto GBA Web Site at include: Going Beyond Diagnosis : The ICF and Decision-Support in Hospice & Palliative Care - (Revised January 2008) Going Beyond Diagnosis : Revised Hospice ALS Local Coverage Determination Going Beyond Diagnosis : Hospice Cardiopulmonary Conditions LCD Going Beyond Diagnosis : Valuable Information (Revised February 2008) Going Beyond Diagnosis : Continuous Quality Improvement By providing context to the documentation of relevant impairments of body functions and/or structures, activity limitations, and participation restrictions, the ICF concepts allow providers to incorporate not only the finite lists of specific eligibility criteria into their processes, but also identify and take into account other important information that may have been previously missed. Utilizing the relevant domains and categories contained in the ICF to supplement the specific eligibility criteria previously listed in the Hospice LCDs will allow the collection of critical information in support of an effective continuous quality assessment and performance improvement program. September 23, 2008 Hospice Coalition Meeting 8

10 One hospice provider has already reported that use of the ICF has identified gaps in their hospice s documentation for individuals with cardiopulmonary conditions. This finding is consistent with Palmetto GBA s own observations that the ICF contains many more relevant pieces of information (i.e., domains and categories) not previously addressed by the Hospice Heart and Hospice Pulmonary LCDs. 5. In determining eligibility criteria for admission to hospice services and continued eligibility, should hospices be utilizing The International Classification of Functioning, Disability and Health developed by WHO or Local Coverage Determinations or a combination of both? The newly revised LCDs recommend the ICF framework for describing the primary condition, secondary condition(s) and any relevant comorbid condition(s) AND their serial impact on the individual and their caregivers. There is no requirement that you use ICF. Each hospice provider will, however, need to determine how best to describe their patient population. The specific data collected at the individual patient level will be driven by the need to collect relevant data to support improvements in palliative outcomes at the organizational level. Data supporting hospice eligibility will, by default, be collected as part of the larger initiative to implement an effective continuous quality assessment and performance improvement program. The challenge will be to collect and report these data in an organized manner one that allows proactive hospice organizations to ask and answer strategic organizational questions. The ability of hospice organizations to leverage information contained in their medical records, in support of quality initiatives, is dependent on a comprehensive approach to strategy-driven data collection. The revised Hospice LCDs provide a roadmap for data collection that will, if incorporated into an effective continuous quality assessment and performance program, support critical decisions, including admission. Please see articles cited under the response to question # 4 for additional information. 6. Considering that a patient is terminally ill, has heart disease, diabetes, COPD, slight dementia, and is losing weight, but does not meet the LCD for any specific diagnosis, should the hospice use general decline and cover all expenses related to the diseases used to support the terminal illness or is it better to select a specific diagnosis? A comprehensive assessment of the individual s health status would identify relevant impairments of structure and/or function, relate them to activity limitations and participation restrictions, and identify opportunities for palliation. As described in the enclosed 1998 article published by Palmetto GBA titled Palmetto GBA s Focused Medical Review (FMR) Non-Cancer Hospice Claims Symptoms, Signs and Ill-defined conditions (ICD-9-CM ) there are times when the impact of more than one diagnosis contributes to the terminal condition. When this occurs hospice providers September 23, 2008 Hospice Coalition Meeting 9

11 should select one of the diagnoses as the principal diagnosis and identify the other diagnoses as relevant secondary and comorbid conditions. With regard to the palliation or management of the terminal illness and related conditions one must go beyond diagnosis and take into account the terminal condition, which in the circumstance described in this question, may involve the palliation of symptoms associated with not only the primary diagnosis, but also identified secondary and comorbid conditions. Additionally please see the enclosed Palmetto GBA article titled Going Beyond Diagnosis : ICD-9-CM Debility Unspecified for a case example. 7. Could you discuss the end-stage renal LCD revisions? They are very general and from what I have read, those lab criteria are no longer required. There is no mention that they are no longer receiving dialysis. Can a patient receive dialysis and hospice under this LCD? Please see the enclosed Palmetto GBA Article (A4630) titled Response to Comments Local Coverage Determination (LCD) Hospice Renal Care for a general discussion of the Hospice Renal LCD revisions. When documented, the specific LCD criteria - including the lab criteria, contained in the previous version of the Hospice Renal LCD - helped describe an individual s medical condition, but not necessarily their health status. Hospice has always been a unique benefit, focused less on the strict medical model and more on the holistic model. The LCD revision took this, and the challenges inherent in establishing the terminal condition for individuals with chronic, disabling conditions, into account. The role of dialysis in the population of individuals otherwise eligible for hospice is a matter best left to the individual and his/her caregiver(s) both formal and informal. For these individuals, the provision of dialysis should not be seen as a barrier to hospice admission, but rather should be incorporated into the discussion of effective or ineffective palliative care options. Based on discussions with nephrologists caring for individuals at the end of life, it is evident that many terminally ill individuals would suspend dialysis treatments, if only they were able to feel confident that their needs at the end of life would be met by a palliative care team. In article A4630, Palmetto GBA described the results of a 2006 retrospective study (N= 115,239) which identified that among a cohort of patients who received dialysis and died during a two-year study period, 15,565 patients (13.5%) also received hospice services. Among the 25,075 study subjects who withdrew from dialysis prior to death, less than half received hospice services - despite evidence supporting that after withdrawal approximately 96% of individuals die within 30 days (Clin J Am Soc Nephrol 1: , 2006). The revised Hospice Renal Care LCD supports the use of both quantitative and qualitative variables in the decision-making processes guiding hospice admissions, recertifications, discharges and level of care decisions. The new hospice condition of participation (CoP) requirement of an effective continuous quality assessment and performance improvement program will provide the means to study and continuously improve palliative outcomes in this population including those who elect the hospice benefit while still receiving dialysis. September 23, 2008 Hospice Coalition Meeting 10

12 8. A few providers have had claims denied because Palmetto GBA changed the admitting diagnosis and then said they didn t meet the LCD for that disease. Upon appeal most are losing even though they are being denied for a different diagnosis. Can Palmetto GBA explain how they can change the diagnosis and what rights the hospice has in these situations? During the initial review process medical reviewers do not change the diagnosis on a claim. The reviewers consider ALL diagnoses on a claim prior to making a decision to deny a claim. Also, during the redetermination process, the letters may list other pertinent diagnoses identified on the claim. For further clarification we ask the provider who submitted this question to bring any specific examples of initial review determinations to the attention of medical review by contacting Lori Strater at (803) If the claim in question is in regard to a redetermination decision, please contact Gayle Jones at (803) in the appeals department for further clarification. 9. What elements will Palmetto GBA look for in the new Comprehensive Assessment documentation? Providers are urged to review the CMS Final Rule (Federal Register/ Vol. 73, No. 109/Thursday, June 5, 2008, pages ) for guidance on comprehensive assessment. Among the guidance provided within the Final Rule is the following narrative: The comprehensive assessment is not a single static document, a symptom and severity checklist, or a set of generic questions that all patients are asked. It is a dynamic process that needs to be documented in an accurate and consistent manner for all patients. 10. If physical therapy is determined as needed for the patient at the initial assessment, does the therapist then have only 5 days to make their assessment? Palmetto GBA is unaware of the requirement listed in the above question. 11. What are some of the specific things (words) that hurt hospice providers in their documentation? There are no specific words that hurt a hospice provider. The medical review is based on a comprehensive review of the entire medical record submitted. 12. Through a Medical Review standpoint are there some areas Palmetto GBA would suggest hospices focus on for their QAPI development? September 23, 2008 Hospice Coalition Meeting 11

13 Providers are urged to review the CMS Final Rule (Federal Register/ Vol. 73, No. 109/Thursday, June 5, 2008, pages ) for guidance on the Quality Assessment and Performance Improvement (QAPI) standards. The Program Activities standard makes it clear that providers should focus on high risk, high volume or problem prone areas. Palmetto GBA is unable to provide suggestions as the focus will, by necessity, vary by provider. The commitment of each hospice provider to an effective continuous quality assessment and performance improvement program as per the CoP will drive this development. 13. We are having great difficulty with hospitals unable to bill for their care PRIOR to hospice admission. For example, we receive referral from hospital, and patient is admitted upon discharge to hospice inpatient facility. The hospitals are being told by their intermediary that they don't care what time the admission occurs, hospice owes the hospital bill. Please advise how to address this issue. Hospices are not responsible for payment of hospital inpatient care provided prior to a beneficiary electing the Hospice Medicare Benefit. However, both the hospital and hospice should ensure that correct dates are being submitted on the claims. Hospitals should ensure they are using the correct patient status code when submitting claims for patients who are being discharged to hospice care. For patient status codes please reference: MedLearn Matters Article, MLN Matters Number: SE0801, revised on November 7, What will the next edits be and when will they occur? Medical Review will be evaluating the most current data including, Non Cancer Lengths of Stay, providers that exceed the hospice cap, new providers and other projects as assigned or determined by referrals. Medical review is a continuing process; edits are initiated as warranted and budgeted. Hospice review is prioritized with the other lines of business. At this time specific dates have not been assigned. 15. Will any new edits be held up until the MAC transition occurs? Medical Review has not received any instructions to change the current process; therefore business will proceed as normal. 16. What will happen to a provider who is under an edit or CMR and is transitioned to a different MAC? How will redeterminations which are in process be handled if a provider is transitioned to a different MAC? This will be determined by the instructions that Palmetto GBA receives from CMS. September 23, 2008 Hospice Coalition Meeting 12

14 17. Can Palmetto GBA provide statistics which allow comparisons between reconsiderations when completed by Palmetto GBA as compared to results since QICs have been handling the appeals? Palmetto GBA does not have the requested comparative information. 18. Where is the NCLOS probe, when is it going to be finished? Which states are still on probe? What phase are they in? What results are available? What are the top five reasons for denial? What new edits will be coming? What have been the outcomes of programs on NCLOS edit who remain under Medical Review beyond four quarters? The Non Cancer Length of Stay (NCLOS) probe reviews of FY 07 and 08 has been completed. All providers placed on probe review have either been removed from review or progressed to other levels of review. For other edits information please see question 14. Providers Selected for NCLOS Probe Review 252 Providers Placed on NCLOS Probe Review 250 Providers Currently on NCLOS Probe Review 0 Providers Currently on NCLOS Complex Review 0 Providers Currently on NCLOS CAP Review What is meant by prolonged review in the PCA Decision Tree? Is that a standard period of time (i.e. 1 year) or is there some subjectivity to that determination? Currently, there is no definitive period of time that is considered "prolonged review". Palmetto GBA makes decisions regarding PCA actions based on improvement, educational activities and corrective action plan documentation. 20. How does Palmetto GBA determine which option to choose for those programs who have little improvement after a corrective action plan has been put in place (i.e. withholding payments, post-payment comprehensive medical review, referral to Payment Safeguard Contractor or referral for program exclusion, suspension of payment or civil monetary penalty)? Palmetto GBA makes determinations based on the length of time a provider has been on review, how egregious the errors are, the dollars determined to be at risk, claim volume as well as the information noted in question 19. September 23, 2008 Hospice Coalition Meeting 13

15 21. In letters from the Medical Review Department, charge denial rates are distributed approximately every three months. Is there any plan from Palmetto GBA to distribute these letters more frequently (monthly) so that charge denial rates may be more closely monitored? Not at this time. Current regulations state that providers should be notified at least every six months either by phone or in writing of their status of review. Palmetto GBA s Medical Review department has always tried to exceed requirements and expectations. As noted in the question, letters are sent quarterly with educational materials, the list of claims reviewed in that time frame and the determinations. Also note that Teaching and Instruction to Provider (TIP) letters are sent out to providers that receive more than one denial in a month. These letters give providers information on the denial and how to avoid this in the future. 22. Tell us about CERT reviews and hospice. Explain the RAC and activities. How is hospice involved? Will hospices be targeted in future RAC activity? CERT reviews claims similarly to Palmetto GBA. From the May 2008 report hospice denials accounted for 31.4% of the dollars paid in error. This made hospice second behind home health. Palmetto GBA can not address CMS plans for the RAC. 23. Can Palmetto GBA factor the total number of patients served by any given hospice before they start making determinations that providers have charge denial rates that appear extremely high for patients served? We understand they calculate on the number of records they are reviewing but they are looking at the most difficult patients to prognosticate in the 1000s of patients served daily, who die well within weeks of admission and this ON-GOING scrutiny of the extreme tail causes hardship and diversion from the majority of the patients the provider may be serving. Medical Review takes into account claims volume, number of beneficiaries, and dollars at risk before selecting a provider to be placed on review, regardless of the reason for the review. When selecting providers based on the Non-Cancer Lengths of Stay rates, the providers are compared to each other and the rate is established based on those billing behaviors. The charge denial rate is based on the dollars denied over the dollars reviewed. The number of beneficiaries an agency has impacts the potential number of claims selected for review. If those claims are paid then the provider would have a low charge denial rate and be removed from review. The medical review department s goal is to ensure that the claims submitted meet the criteria established for the benefit. Providers remain on review if the necessary requirements are not met. If a provider has a hardship we also work to address those issues. This is done thorough decrease in review percentages, as much education as possible to ensure accuracy of documentation, and ensuring that providers receive credit for overturned decisions. September 23, 2008 Hospice Coalition Meeting 14

16 24. Explain the charge denial rate? How are the claims dollars used in calculating the CDR? To calculate the charge denial rate we capture the total number of claims reviewed and processed for the quarter and establish the dollars associated with those claims. This is done by determining what the claim would have paid if it had not been reviewed. We then calculate the dollars denied for those claims. We divide the dollars denied by the total dollars reviewed. Then multiply that number by 100 for the percentage. ADR Example: $25, denied =.25 x 100 = 25% $100, reviewed 1. Hospice organizations are held to deadlines in submitting responses to ADRs or they receive an automatic denial. If decisions are not made by Palmetto GBA regarding an ADR per the allotted time, does that result in automatic payment of the ADR? Medicare regulations require medical reviews to be completed within 60 days of the receipt of the medical records. Palmetto GBA meets the timeliness standards set by CMS. Failure to meet this standard would not result in automatic payment of the claim. It is important to note that although the review may be completed within the 60 day standard, the claim must still continue through other processing phases including but not limited to CWF. 2. ADRs are being lost at Palmetto GBA and automatic denials for Non Receipt are being rendered when we have evidence of FED EX deliveries. Why are these being asked to be resent, a labor and cost expense to the provider as well as the provider having that denial entered into their analysis calculation? Due to this being Palmetto GBA error, it seems Palmetto GBA needs to dismiss that record as the reopening may not even be reversed in the same analysis period? Please Comment. If you have sent records and have a signed receipt, contact medical review with the receipt information including the name of the employee that signed for the package for Palmetto GBA to research. September 23, 2008 Hospice Coalition Meeting 15

17 Actions a provider can take to ensure that records reached the appropriate destination include: Making sure the mail code is listed in the address; Making sure that beneficiary records are individually identifiable, like colored paper between each record being sent, using a manifest to document which records should be in that particular package; Performing a quality check to make sure that the records you document as being in the package are actually in the package; Making sure that once you ship a record check DDE for a change in status/location of the claim; As for the calculation of the charge denial rate; it is based on processed claims. If a provider receives a denial, they should request a reopen as soon as possible. The edit effectiveness reports are done quarterly not monthly so in most cases, providers have the opportunity to address these types of situations before it is too late. To that extent any claim overturned that was not adjusted during the current quarter, will be calculated in the next quarter s statistics and the provider given credit. The s will not be dismissed, as the manual instructs Palmetto GBA to deny if the records are not received in medical review within thirty days. The denial is not actually generated until the claim is forty-five days past due. On day 30 if a provider realizes that the medical record should have been received and the claim has not been moved out of status/location SB6001, contact us, provide the details you have related to your submission of the record (e.g. did you send other records in the same package, was it overnight mail, signed receipt, etc.). We will begin researching the issue at that time. 3. Are there any plans to have available on the Palmetto GBA website, the status of ADRs and the appeals process? It is difficult to ascertain this status on the Direct Data Entry (DDE) website. There are no plans to load ADR or appeals information on the Palmetto GBA Web Site at this time. 4. We are expected to process and submit sometimes large volumes (50-70) of ADR charts. Is Palmetto GBA now staffed to process that same volume on review within their 60 day process?? Often analyses are rendered and the bulk of charts have not been reviewed in the same expected time frame. September 23, 2008 Hospice Coalition Meeting 16

18 Palmetto GBA s medical review department continues to meet the timeliness standards set by CMS. Data analysis and decisions are rendered based on the claims that have been reviewed and processed during the current quarter. Claims are reviewed in the order in which the records are received. Only processed claims are listed on analysis reports. Claims that do not fully process due to sequential billing or other claims processing issues, although reviewed by medical review, will not appear on the report until the claim finalizes. 5. What is the relationship between the Non-Cancer Length of Stay (NCLOS) rate and the ADR Process? The Non-Cancer Length of Stay (NCLOS) rate is one of the many tools used to mine data and establish areas of focus. Because NCLOS has been a successful tool in identifying providers that may need education, claims review or referrals, we continue to use it. Other sources are national, claims processing and lengths of stay data not based on non-cancer diagnoses. An ADR may be generated based on a service, a provider, a beneficiary, a diagnosis, or just about any field on the claim if an edit is established for that reason. Edits are established based on data analysis or identified problem (e.g. CMS referrals, other governmental agency, Survey and Cert initiatives). Advanced Beneficiary Notices (ABNs) 1. ABNs are provided to beneficiaries to convey that Medicare is not likely to provide coverage in a specific case and must be delivered far enough in advance that the beneficiary has the time to consider options and make an informed choice. Can Palmetto GBA provide guidance on whether an ABN is required in the following: a. No longer medically eligible Ineligibility because the beneficiary is not terminally ill as defined in 1879(g)(2) of the Act would require issuance of the ABN. b. Level of care (GIP, Respite, Continuous) when the hospice determines the level of care is not reasonable and necessary to manage the terminal illness yet the patient refuses to be moved from the inpatient setting (GIP and Respite) or demands that continuous care be continued. Issuance of an ABN would be required when the level of hospice care is determined to be not reasonable or medically necessary specifically for the management of the terminal illness and/or related conditions. September 23, 2008 Hospice Coalition Meeting 17

19 c. Hospitalization without hospice approval, i.e. not in the hospice plan of care as they are not considered medically reasonable and necessary for providing care related to the terminal illness. It is the responsibility of the provider to issue an ABN when a beneficiary who has elected the hospice benefit chooses to receive care in a hospital that is not under contract with the hospice or if the beneficiary continues an inpatient hospital stay, which is no longer deemed medically necessary by the hospice. The hospice may delegate delivery of the ABN to the hospital in these cases. As a reminder, the hospice agency remains the professional manager of the patient's care. It is the responsibility of the hospice to educate the patient and representative/family upon admission as to what the Hospice Medicare Benefit entails. This includes educating them on the need to seek pre-approval from the hospice prior to entering the hospital. This statement should be on the Notice of Election explaining the HMB and the need to seek pre-approval or financial responsibility could lie with the patient for any bills incurred. Providers need to ensure that the beneficiary/representative understands this statement. d. Medications, diagnostic testing and treatments not in the hospice plan of care as they are not considered medically reasonable and necessary for providing care related to the terminal illness but which the patient demands be provided. Since hospices are paid under a per diem rate, it does not seem that separate items could be unbundled and a patient issued an ABN. Please explain if these types of individual items and services would need an ABN how that would work. Specific items or services that are billed separately from the hospice payment, that are not reasonable and necessary for the management of the terminal illness and/or related conditions, would require issuance of the ABN. e. Physician services billed separately from the hospice per diem payment which are not reasonable and necessary. See D above. f. Do we no longer provide QIO/appeal information along with or on the new form The expedited determination notice and the ABN must be issued together only when all covered care is being terminated for coverage reasons and the beneficiary is expected to continue receiving non-covered care. CMS Change Request 6136, issued September 5, 2008 with an implementation date of March 1, 2009: Revised Form CMS-R-131 Advance Beneficiary Notice of Non- Coverage September 23, 2008 Hospice Coalition Meeting 18

20 For complete ABN instructions and a copy of the Revised Form CMS-R-131 Advance Beneficiary Notice of Non-Coverage: CMS Manual Systems, Pub Claims Processing; Chapter 30 Financial Liability Protections; Section What should a hospice do when a patient asks for assistance in deciding between the options on the new ABN form? Providers can reference the following information when explaining the new ABN form to beneficiaries and/or their representatives: CMS Change Request 6136, dated September 5, 2008 with an implementation date of March 1, 2009 outlines the Revised Form CMS-R-131 Advance Beneficiary Notice of Non-coverage. CR 6136 announces that, effective March 3, 2008, the Centers for Medicare & Medicaid Services (CMS) implemented use of the revised Advance Beneficiary Notice of Noncoverage (ABN); which combines the general Advance Beneficiary Notice (ABN-G) and laboratory Advance Beneficiary Notice (ABN-L) into a single form, with form number (CMS R-131). Providers should be aware that beginning March 3, 2008 and prior to March 1, 2009, Palmetto GBA will accept either the current ABN-G and ABN-L or the revised ABN as valid notification. However, beginning March 1, 2009, Medicare contractors will accept only a properly executed revised ABN (CMS R-131) as valid notification. The Medicare Claims Processing Manual Chapter 30 (Financial Liability Protections), Section 50 (Form CMS-R-131 Advance Beneficiary Notice of Noncoverage (ABN)) has been substantially updated to reflect these changes. The revised notice incorporates suggestions for changes made by users of the ABN and by beneficiary advocates based on experience with the current form, refinements made to similar liability notices through consumer testing and other means, as well as related Medicare policy changes and clarifications occurring in the same interval. Additional changes made to the form were based on comments and suggestions made during the recent public comment period. 3. What does a hospice do if a patient refuses to sign the ABN? According to the Advance Beneficiary Notice of Noncoverage (ABN) instructions found on the CMS Web Site at the beneficiary (or representative) must sign the ABN in section I to indicate that he or she has received the notice and understands its contents. If a representative signs on behalf of a beneficiary, he or she should write out representative in parentheses after his or her signature. The representative s name should be clearly legible or noted in print. September 23, 2008 Hospice Coalition Meeting 19

21 If the beneficiary refuses to choose an option and/or refuses to sign the ABN when required, the hospice agency should annotate the original copy of the ABN indicating the refusal to sign and may list a witness to the refusal on the notice. If a beneficiary refuses to sign a properly delivered ABN, the agency should consider not furnishing the item/service, unless the consequences are such that is not an option. (e.g., health and safety of the patient or civil liability in the case of harm.) The hospice agency must provide a copy of the annotated ABN to the beneficiary, and keep the original version of the annotated notice in the patient s file Contrast the differences between ABN and Generic notice for hospice. When is it appropriate to use the Generic notice and how it relates to ABN? When planning for a live discharge and not knowing how the beneficiary will react or if the QIO will become involved, which notice is most appropriate to use and give to the beneficiary when the physician and team believe the beneficiary no longer meets terminally ill criteria? Hospice providers must use expedited determination ( Generic ) notices in accordance with 1869 of the Act when required. Expedited determination notices are given to beneficiaries when all Medicare covered services are being terminated for coverage reasons, so beneficiaries are alerted to their right to obtain an independent, immediate Quality Improvement Organization (QIO) review of the decision to end coverage. The expedited determination notice and the ABN must be issued together only when all covered care is being terminated for coverage reasons and the beneficiary is expected to continue receiving noncovered care by that provider. For detailed instructions regarding the delivery of the expedited determination notice, see Transmittal 594, Change Request 3903, dated June 24, 2005 and the subsequent Questions and Answers on: CMS Internet Only Manual, Pub Claims Processing Manual, Chapter 30 Financial Liability Protections, Section Expedited Determination Notices (Rev.1587, Issued: , Effective: , Implementation: ) 5. What action should a provider take when a QIO overturns the hospice decision to discharge via a generic notice and the hospice medical director refuses to subsequently certify the patient? This question was answered in the Hospice Coalition questions dated April 2007 on the Palmetto GBA Web Site at September 23, 2008 Hospice Coalition Meeting 20

22 The QIO review determination establishes the level of care of the beneficiary at the time the notice was issued. This determination is a medical decision, based on the medical record documentation provided to the QIO by the Hospice along with information received from the beneficiary's physician. The QIO's review determination establishes who will be liable for payment of the services if the services continue to be rendered. However, the QIO's decision does not ensure that the services will be provided. We are aware that the Hospice provider cannot deliver services without a physician's order and physician's certification. However, if the medical determination is that services should continue and/or the physician's actions had a negative impact on the quality of care the beneficiary received, the QIO may choose to process the case as a quality of care review. In order to ensure that the patient receives the best quality of care, Palmetto GBA recommends that the Hospice Medical Director and/or the attending physician conference with the QIO physician. That would give them the opportunity to discuss questions and/or issues about coverage determinations. 6. In a phone conversation with medical director of FMQAI (Florida Medical Quality Assurance Initiatives) and also stated in a phone conversation with Michael Taylor from CMS Regional Office Atlanta, on June 5, 2008, inquiries were made regarding the authority of the FMQAI to over-rule discharge decisions on patients appeals. According to Michael Taylor, the appeals decision by the FMQAI is binding on hospice organizations as well as the fiscal intermediaries. Mr. Taylor also stated that once a favorable decision is rendered that a patient is appropriate to receive hospice services then the discharge should not proceed. He further stated that such decisions also qualify the patient as appropriate for purposes of reimbursement. If the decision by the FMQAI is binding, where is this written in the regulations and what is Palmetto GBA s position from this perspective? Palmetto GBA, along with providers, received the following direction from CMS in 2005: As of July 1, 2005, Hospice and Home Health Agencies are required to notify beneficiaries of their right to a new expedited review process when these providers anticipate that Medicare coverage of their services will end. Therefore, hospice providers are required to provide a Generic Notice to beneficiaries to alert them that Medicare covered item(s) and/or service(s) are ending and give beneficiaries the opportunity to request an expedited determination from a QIO. A Detailed Notice is given when the QIO review is requested in order to provide more explanation on why coverage is ending. September 23, 2008 Hospice Coalition Meeting 21

23 Hospice providers must use expedited determination ( Generic ) notices in accordance with 1869 of the Act when required. Expedited determination notices are given to beneficiaries when all Medicare covered services are being terminated for coverage reasons, so beneficiaries are alerted to their right to obtain an independent, immediate Quality Improvement Organization (QIO) review of the decision to end coverage. The beneficiary may also request a reconsideration of the QIO s decision by a Qualified Independent Contractor (QIC). Once the QIO/QIC has made a decision at the end of the review, providers may bill for the period reviewed in accordance with the QIO/QIC decision on coverage. The standard appeal rights will still apply to the reviewed claims. To review more information about this subject, download current forms and view Questions and Answers on this process please go to: CMS Internet Only Manual, Pub Claims Processing; Chapter 30 Financial Liability Protections; Section Expedited Determination Notices (Rev.1587, Issued: , Effective: , Implementation: ) 7. If under Medical Review (NCLOS), a patient is determined by Palmetto GBA to be not hospice appropriate and was reviewed upon discharge by Medicare s Quality Independent Contractor (QIC) and deemed appropriate, how does the review process utilize that information? Does it make sense that one arm of Medicare claims the patient is appropriate and another claims the patient is not? Cap Palmetto GBA is uncertain if the question is related to Qualified Independent Contractor (2nd level appeal) or the Quality Improvement Organization (expedited review determinations). Palmetto GBA does take redetermination and second level appeal decisions into account when making PCA decisions. The QIO is responsible for sending decisions related to the appropriateness of discharge to the Palmetto GBA claims department. 1. Please provide the most recent Cap results and an update on the 06 Cap demand letters by state. Attachment B (Data current as of 9/10/2008) a. How many hospices does Palmetto GBA expect to review for 2006 Cap and how many have been reviewed thus far? We will review 1154 hospices for 2006 Cap period. We have completed reviews for 1117 providers with 37 left to complete. September 23, 2008 Hospice Coalition Meeting 22

24 b. How many Cap demand letters have been sent out thus far, for how much? We have sent out 196 cap overpayment demand letters. The total net overpayment amount for these is $161,139,685. c. How many of the Hospices receiving 06 demand letters thus far exceeded the cap for the first time in 06? There were 68 providers who exceeded the cap for the first time for 2006 cap period. Of these, 18 providers had their first cap review for 2006 cap period. Continuous Care 1. The following case is an example of challenges that hospice providers have in determining if a beneficiary qualifies for the continuous care level of care. Can Palmetto GBA provide guidance related to this case which can help providers with other cases as the struggle to determine the appropriateness for continuous care? The patient details provided in the above example have been retracted for privacy issues. The case scenario involved a caregiver that planned a trip out of town and is unable to use the privately hired caregiver she has used in the past due to an illness. Continuous Home Care (CHC) is provided during a period of crisis. The Centers for Medicare & Medicaid Services (CMS) defines a period of crisis as a period in which a patient requires continuous care which is primarily nursing care to achieve palliation or management of acute medical symptoms. In the above example, Respite Care would be the appropriate level of care. Respite Care is provided to give the caregiver respite or relief. Respite Care is performed in a participating Hospice Inpatient Unit, participating hospital, Skilled Nursing Facility (SNF) or Nursing Facility. Respite Care is the only level of care that is used for the needs of the caregiver. Respite Care is provided for a maximum of five (5) consecutive days. Payment for the sixth and subsequent days and the day of discharge from Respite Care is paid at the Routine Home Care rate. 2. Currently it states In the Palmetto GBA Training Manual; documentation for continuous care should illustrate hour by hour and day by day what services were provided With reimbursement based on 15 minute increments, should documentation be in 15 minute increments or hour by hour and more often if the patient s condition changes? The Palmetto GBA Home Health and Hospice Manuals were retired and removed from the Palmetto GBA Web Site in Providers should utilize the CMS Internet Only Manuals at to obtain coverage and billing information. September 23, 2008 Hospice Coalition Meeting 23

25 Other: Continuous Care documentation should be illustrated hour by hour and day by day, however, documentation does not have to be done in 15 minute increments. CHC is billed in 15 minute increments in accordance with the guidelines in Change Request When will all Pricer errors be corrected and the over and underpayment take backs begin? Palmetto GBA is not aware of any Pricer issues regarding hospice claims resulting in over and under paid claims. Please provide us with examples for additional research. 2. When will Palmetto GBA the 855s be caught up? We have providers that have waited a year for addresses to be changed. Palmetto GBA Provider Enrollment is continuing to work out of an existing backlog situation. We expect reductions in on-hand pending to be greatly reduced over the next 6 months. Specific issues may be addressed to Teresa Newton, Manager Provider Enrollment at (803) or teresa.newton@palmettogba.com for resolution. 3. How will the IRS notify Palmetto GBA when back taxes are to be paid? Since that begins October 1, 2008 are those programming changes already in place in the FISS? Palmetto GBA has not received information on how the IRS will notify the intermediaries when back taxes will be paid. The FISS changes associated with CR6125 are in test now and are scheduled for implementation on 10/6/ Who identifies for Palmetto GBA that a provider has violated the Non-compliance with the physician self-referral prohibition legislation or payer policy Change Request 6131, so that that provider claim will be denied with reason code #213? Carriers, FIs, A/B MACs, RHHIs, and DME MACs (effective January 1, 2009) are required to use the new Claim Adjustment Reason Code (CARC) #213 when denying claims based on non-compliance with the physician self-referral prohibition. Transmittal 1578, August 15, 2008, Is that programming to deny those payments already in FISS? It is CMS and the Office of the Inspector Generals (OIG) responsibility to make a determination that there is a violation of the physician self-referral prohibition. However, if in the normal scope of work, a intermediary identifies a problem, they should present the issue to the appropriate CMS or OIG personnel for a determination. If subsequently a determination is made that there is a violation of the physician selfreferral prohibition, then a recoupment of any paid claims would be made. The recoupment of payment would be indicated by using a denial code. This type of recoupment is usually done post-pay; however, it is a violation of the physician selfreferral prohibition for providers of designated health services to submit a claim to Medicare for any prohibited referral. September 23, 2008 Hospice Coalition Meeting 24

26 5. Medicare Fraud Edit Module Phase 3, Transmittal 265, August 8, 2008, CR 6135, this is directed at all provider types but more specifically at DME providers? It describes the problems with DME in Florida and spreading to other states, but the latter part talk about hours of care provided for longer length of time than usually seen. How does Palmetto GBA see this being implemented, state by state, region by region, FI by FI? Will they start with the DME companies or target everyone at the same time? Palmetto GBA has not received directives from Centers for Medicare & Medicaid Services (CMS) on the implementation of Change Request (CR) 6135, as it relates to RHHI providers. 6. Can you give us any information on the Physician Quality Reporting Initiative (PQRI) program and changes that hospice providers need to begin thinking about related to these program needs? In 2012 physicians will lose 1% of reimbursement for not using the PQRI program. How or will this effect hospice? This CR is specifically directed at Medicare Carriers and Medicare Administrative Contractors who process claims for Medicare Part B services, which include physician services. As such, the PQRI program does not pertain to Hospice providers as they submit claims to the Regional Home Health and Hospice Intermediary. 7. Why is it taking so long for the rejection error to be corrected by Palmetto GBA? Per their request I have re-billed 3 claims just to make sure that it would not error out again and it did. Reason code is the result of a billing error. More specifically, providers may receive this reason code for one or more of the following reasons: Attending Physician NPI is not submitted on the claim Physician s UPIN is submitted versus Physician s NPI Physician s UPIN and NPI submitted on the claim Providers receiving reason code for reasons other than the above scenarios should provide specific examples for additional research. 8. When patients go from private insurance/private pay to Medicare our biller uses the date that the patient was admitted to hospice and it does not coincide with the Medicare certification period, it seems to cause continuous delays in our reimbursement. We have to change our admit date to coincide with the beginning of the Medicare certification period. Should we have to change our admit date when this happens? If so, do we need to redo all our admission paperwork? Why does this hang up in the Medicare system when we do not change the admit date? September 23, 2008 Hospice Coalition Meeting 25

27 When a beneficiary either becomes eligible for Medicare or otherwise elects the hospice Medicare benefit, traditional Medicare fee for service becomes the primary insurance for the beneficiary. As with any insurance, an admission date for entitlement for said benefit is posted to the Common Working File (CWF). The logic is the same if the beneficiary has been private pay. This notification of the CWF occurs when the provider submits the Notice of Election. The CWF edits claims for validity, entitlement, remaining benefits, and deductible status. The objectives of the CWF are to provide complete beneficiary information to Medicare contractors as to entitlement data, admission dates, utilization data, and claim history. Hospice providers do not show days before the patient s Medicare hospice entitlement began. Therefore, all paperwork will need to reflect the date that the beneficiary has elected the HMB. Admission dates for other payer sources may not be used. CMS Internet Only Manual, Pub Medicare Claims Processing Manual; Chapter 11 Processing Hospice Claims 9. Report the QIO activity on the PEACE project document and generic notice. Information on the PEACE project should be obtained by contacting the QIO or visiting their Web Site at www2.thecarolinascenter.org. Attachment C 10. Care Plan Oversight: Is this paid differently for physicians covering nursing home patients? How is it billed? Can NPs do this? Section of CMS IOM Publication , Chapter 11, defines Care plan oversight (CPO), and states, For a physician or NP employed by or under arrangement with a hospice agency, CPO functions are incorporated and are part of the hospice per diem payment and as such may not be separately billed. For specifics on billing Care Plan Oversight, providers should contact their Part B carrier. 11. If patients are admitted to a different hospice and all billing has not been submitted from the prior hospice provider, will bills dropped from the new provider be automatically denied? Hospice claims MUST be submitted in sequential order. If a patient is discharged or transferred from a hospice agency, a proper discharge bill should be submitted to the intermediary (claims should have the occurrence code 42 to indicate a discharge from the hospice agency). The hospice agency picking up the patient would then be able to bill their claims in sequential order. If a hospice agency does not bill a discharge claim prior to the other hospice agency billing their claims, the receiving agency would need to cancel all the claims billed, wait for the hospice agency to bill their discharge claim and then resubmit their claims to ensure sequential order. Timely billing is important. September 23, 2008 Hospice Coalition Meeting 26

28 Providers who have difficulty getting an agency to bill a discharge claim should try to work this out among the two agencies. If there is a refusal to bill the discharge claim, providers should call the provider contact center at (866) Is it acceptable for a hospice employed physician to serve as the hospice attending when a hospitalized patient is admitted to hospice while in the hospital and the hospice physician does not have admitting privileges in that hospital, if the patient chooses the hospice physician as attending? If a beneficiary does not have an attending physician or a nurse practitioner who has provided primary care prior to or at the time of the terminal diagnosis, the beneficiary may choose to be served by either a physician or a nurse practitioner who is employed by the hospice. The beneficiary must be provided with a choice of a physician or a nurse practitioner. CMS Internet Only Manual, Publication , Chapter 9 Section Moreover, it is the responsibility of the hospice agency to establish agreements and/or contracts with a hospital relevant to rendering services to hospice patients. 13. Due to recent system changes and site location changes at Palmetto GBA, when will the new Provider Reimbursement Account representatives be assigned? In the mean time, will a list of individual contacts be provided to hospices so that we may address our concerns to a specific person? Please refer to Attachment A regarding Palm Harbor, Florida Audit and Reimbursement Migration to the South Carolina Home Office. Providers should direct all calls regarding reimbursement concerns to the Provider Contact Center (PCC) (866) A Member Service Representative (MSR) in the contact center will forward all reimbursement questions or concerns to the appropriate Reimbursement Consultant. 14. Claims Problem: Claims in SMSADJ status are remaining in that status for long periods of time. Example: A claim for dates of service 11/16/07-11/30/07 paid- Keyed 817 to add 2 physician services claims- Claim went to Medicare 03/12/08 and has been the system with SMSADJ since that date. Is there a fix waiting to occur or other software concerns going on we need to be aware of? This status and location holds claims which many different scenarios. For questions on specific claims in this status and location please call the provider contact center at (866) NOTE: At Palmetto GBA, as we developed our business, we began to develop our brand identity. The first change in this development came in 2000 with our name change to Palmetto GBA in an effort to establish a separate identity between our Medicare and TRICARE business. While we recognize that it is convenient to shorten September 23, 2008 Hospice Coalition Meeting 27

29 the name, we ask that you refer to the company, verbally and in writing, as Palmetto GBA, even on second reference and beyond. September 23, 2008 Hospice Coalition Meeting 28

30 ATTACHMENT A Effective August 22, 2008: Palm Harbor, Florida Audit and Reimbursement Migration to the South Carolina Home Office Attention home health and hospice providers. This is to notify you that Palmetto GBA will discontinue Medicare Provider Audit and Reimbursement operations at the Palm Harbor, Florida location effective August 22, The Provider Audit and Reimbursement activities will be transferred from Palm Harbor, Florida to Columbia, South Carolina. The decision to restructure was made to achieve the most efficient cost structure for future service of the Medicare program. Workload transition activities will commence immediately. We request that all correspondence relating to home health and hospice cost report and reimbursement concerns previously directed to our Palm Harbor office now be submitted to the following addresses: Provider Audit: This would include documentation relating to cost report audits or settlements. Palmetto GBA Provider Audit Mail Code AG-320 Post Office Box Columbia, SC Or for courier service: Palmetto GBA Provider Audit Mail Code AG Springdale Drive, Building One Camden, SC Provider Reimbursement: This would include filing cost reports and information submitted for hospice PIP reviews, hospice CAP calculations, and other reimbursement related items. Palmetto GBA Provider Reimbursement Mail Code AG-330 Post Office Box Columbia, SC Or for courier service: Palmetto GBA Provider Reimbursement Mail Code AG Springdale Drive, Building One Camden, SC Palmetto GBA is committed to completing this transfer with minimal to no disruption to the provider community. Thank you in advance for your understanding and support.

31 Palmetto GBA - Palm Harbor 2006 Hospice Cap Overpayments by State AS OF 9/10/08 Attachment B Item State Total % completed 2006 is first O/P # Code State Providers Completed With O/P with O/P Cap O/P Amount 1 1 Alabama % 9 ($47,972,054) 2 3 Arizona % 0 ($6,114,762) 3 4 Arkansas % 1 ($473,812) 4 5 California % 5 6 Colorada % 6 7 New Jersey % 7 8 Delaware % 8 10 Florida % 2 ($4,259,877) 9 11 Georgia % 7 ($6,698,003) Illinois % 2 ($913,645) Indiana % 1 ($666,233) Iowa % Kansas % 0 ($815,797) Kentucky % Louisiana % 5 ($2,253,990) Massachusetts % Michigan % Minnesota % Mississippi % 8 ($41,179,760) Missouri % 1 ($83,287) Nebraska % Nevada % New Jersey % 1 ($260,168) New Mexico % 1 ($5,194,983) New York % North Carolina % 4 ($15,042,454) Ohio % 2 ($1,680,878) Oklahoma % 11 ($17,553,861) Pennsylvania % South Carolina % 3 ($2,776,720) Tennessee % Texas % 10 ($7,052,315) Utah % 0 ($147,086) Virginia % West Virginia % Wisconsin % TOTAL 1,154 1, % 68 ($161,139,685)

32 Attachment C Palliative Care Quality Measures Project Summary Background Quality of care provided at the end of life cannot be assessed with the same approach as is used in other settings for two primary reasons. Treatment goals for this population are focused on matching care to patients expressed needs and preferences. Some traditional treatment goals prolonging life or maximizing function are no longer relevant or desired. In addition, the focus of the care includes family and caregivers to an extent not seen in other care settings. This report summarizes the work conducted on the PEACE Project, sponsored by the Centers for Medicare & Medicaid Services and conducted by The Carolinas Center for Medical Excellence, the Quality Improvement Organization for North and South Carolina. The goal of the project was identify quality measure for use in end of life care and develop an instrument to measure quality of care. Methods The project included many discrete tasks most of which were designed to inform the development of quality measures. A review of instruments to assess patient conditions important in end of life care (e.g.: pain assessment instruments) was conducted to evaluate the suitability of instruments for use in hospice and palliative care. Existing quality measures were reviewed and presented to technical experts with the goal of identifying measures for use in end of life care. A data collection tool was piloted and revised in order to create a tool that could be used by hospices to monitor quality of care. Two special investigative reports were written to understand the potential role of autopsy and the impact of electronic health records on quality of care in hospice and palliative settings. Results The project resulted in three main deliverables that can be shared with hospice and palliative care providers. The first is a list of instruments for assessing patient conditions that have scientific merit 1