Palmetto GBA Hospice Coalition Questions & Answers

Transcription

1 Palmetto GBA Hospice Coalition Questions & Answers November 13, 2007

2 To: Hospice Coalition Members From: Palmetto GBA Provider Education Date: November 13, 2007 Location: Palmetto GBA Attachment A: Attachment B: Attachment C: Attachment D: Attachment E: CAP Information by State Going beyond Diagnosis Case Scenario Going Beyond Diagnosis Worksheet Redetermination/Appeals Report Medicare Learning Network (MLN) Matters Article General Questions: 1) Occasionally a patient s eligibility for Medicare will occur retroactively, i.e. the patient is admitted on March 1 st as a charity care and in August the patient is found in the system as Medicare eligible with an effective date of March (they did not show up in the system until August). How should the election and certifications be handled so the hospice can be paid back to March? As long as the hospice certification and election statement for Medicare is dated in March then the services can be billed for the March dates of service. 2) A patient may change hospice providers one time in a benefit period by filing a statement with the both hospice providers that includes the names of the hospice and the effective date of change. Since this occurs within a benefit period which has been certified according to regulation, is it necessary for the new hospice to obtain new certification statements and if so, how would those certification dates align with the existing benefit period? Terri Deutch offered information on a recent CMS open door forum that the new hospice would need to obtain a new certification statement. This appears to differ from our previous understanding and direction. Yes, there needs to be a new initial certification as the hospice medical director must certify that the person has a terminal illness. However, a new election period would not be required if there is no break in the service dates. November 13, 2007 Hospice Coalition Q & A 1

3 3) When a hospice provider has multiple locations with multiple Medicare provider numbers and a patient moves back and forth between provider numbers, please advise us on how to handle this situation from a billing perspective? There are several options a provider may consider when a patient moves or travels between providers. The options listed below can be found in detail by referencing the Palmetto GBA Hospice Training Manual Notice of Change: 81C/82C Traveling Between Providers Short Absences Providers are reminded in accordance with Change Request 5670, Transmittal 1304, dated, November 2, 2007, for dates of service on or after July 1, 2008, Medicare claims for all levels of hospice care, including inpatient hospice levels of care, shall be adjusted using the Core Based Statistical Area (CBSA) for the location where services are furnished. 4) Can a routine med change always justify be a reason for GIP LOC? This question needs further information on the definition of routine medication change. General inpatient level of care is a short-term level of care. The key is the patient s medical condition. If based on the documentation submitted, the inpatient stay is not reasonable, necessary or related to the terminal illness; the days may be reduced to the routine care day rate. Examples of situations appropriate for short term general inpatient care: Medication adjustment Observation Stabilizing treatment A patient whose family is unwilling to permit the needed care to be furnished in the home. 5) Hospices are required to bill monthly. Does this preclude more frequent billing? If yes, i.e. billing is only permitted monthly, how should a claim be handled if a patient changes their attending physician during a month? How should a claim be handled if a terminal diagnosis changes? In accordance with Centers for Medicare and Medicaid Services, Internet Only Manual, Publication , Chapter 11, hospice providers are to do monthly billing. Therefore, if the attending physician or terminal diagnosis changes during a month, it would not make a difference to the review of the claim. The diagnosis can be changed on the next claim billed, or if the claim is selected for review, the provider can submit a corrected UB04 along with the ADR response. November 13, 2007 Hospice Coalition Q & A 2

4 6) When an ADR is under review, does sequential billing halt the payment for that beneficiary? What happens if we continue to bill? Under the ADR process, sequential billing does not stop. However, if a claim is in the process of being reviewed, any claims submitted subsequent to that claim that are not selected for review will be placed in a hold status until the review has been completed on the claim that is currently an ADR claim. Once the claim selected for ADR has completely processed (either paid or denied), all subsequent claims on hold will process in sequential order. 7) When an ADR is denied, what happens to subsequent claims, i.e. will they be automatically denied? When a claim on which an ADR is generated is denied for lack of medical necessity, subsequent claims on the specific beneficiary will be reviewed. Each claim is reviewed on its own merit. The subsequent claims will be reviewed based on the documentation submitted, it will not automatically deny. 8) The industry recently was provided information on physician billing instructing hospices that the Part A FIs would provide clarification on CPT codes when the hospice physician provides care in the general inpatient level of care when in the following, i.e. is it based on location of care? a) Hospital contracted bed b) SNF contracted bed c) Hospital based hospice inpatient unit d) SNF based hospice inpatient unit e) Free-standing hospice inpatient unit CPT codes are used to define the specific type of service that was provided. Therefore, Hospices billing for physician services are to bill with revenue code 0657 and include the appropriate CPT code for the specific type of service that was provided (e.g., office visit). In addition, effective for dates of service on or after July 1, 2008, hospice agencies will be required to enter the G8 value code with the appropriate Core Based Statistical Area (CBSA) for Inpatient Respite Care and General Inpatient Care (revenue codes 0655 and 0656), which is the location where the care was provided. The CBSA codes can be found on Palmetto GBA s Internet Web site at Once in the site, select Tools and Calculators from the drop down box on the top right side of the screen. On the next page, select Hospice Rate Calculator from the menu in the middle of the screen. Questions regarding the appropriate CPT code should be directed to the American Medical Association at (800) November 13, 2007 Hospice Coalition Q & A 3

5 9) A non-contracted physician provides a service related to the terminal illness without the hospice s knowledge. The hospice becomes aware of the treatment and develops a contract with the physician that has an effective date prior to the date of service. May the hospice bill for that service? Contracts between a hospice and a physician should be established prior to services being rendered. Hence, providers should bill within the contract dates made and agreed upon by the hospice and the physician. Medical Review/Appeals 10) When physicians evaluate patients eligibility, they review not only the terminal diagnosis but the whole patient including co-morbid conditions and the impact these co-morbidities may have on the terminal prognosis. Can you help us understand why denials are issued because the patient would not meet guidelines to use that co-morbid condition as an actual diagnosis? In other words, it seems that we are being issued denials when the use of comorbidity to help support eligibility is in effect invalidated when the co-morbidity was not severe enough to qualify on its own for a terminal prognosis. Eligibility is based on the whole patient as indicated in the question. Medical reviewers look at the entire picture of the beneficiary when reviewing a claim. All diagnoses, including co-morbid and secondary conditions are factored in when making a determination. The co-morbid condition by itself would not be a basis for denying a claim. 11) When does Palmetto GBA expect you will be able to accommodate electronic (i.e., PDF format) submission of medical records for ADRs? Currently, CMS has not approved any electronic records receipt for the medical review of claims. 12) Will a claim ever be denied if the patient dies from the terminal illness during the period under review? Claims may be denied when the medical record submitted does not contain a notice of election (NOE), the NOE submitted is not valid, the certification of terminal illness is not submitted or the certification is not valid. 13) Please explain the process used to determine hospice appropriateness during Additional Documentation Request (ADR) reviews when the patient has a diagnosis that does not correspond to one of the currently defined local coverage determinations. For claims with diagnoses not identified within current local coverage determinations, the documentation submitted is reviewed on an individual basis. The documentation is evaluated on the basis of structural impairments, functional impairments, and activity November 13, 2007 Hospice Coalition Q & A 4

6 limitations, along with the impact of co-morbid and secondary conditions. If the information submitted supports the six month prognosis the claim may be processed for payment. 14) Please provide an update on the current NCLOS probe edit? Give us the number of programs initially on as well as those that remain on NCLOS probes. Can you give us the NCLOS probe via each state? Number of medical denials and non-medical denials. Update us on claims and ALJ activity. There were 252 providers selected for the NCLOS probe review. Of that, 250 providers completed the probe review. This review was not based on state. Medical Review does not have any information on ALJ activity. Once a quarter, an article titled Medical Review Top Denial Reason Codes is published in the Medicare Advisory. This article contains the top denial reasons, and resources for how to prevent future denials. 15) What are the top 5 or 10 reasons for denials? This information is published in the Medicare Advisory quarterly. Previously the top denial information was published monthly; the most recent article was published in the November 2007 Medicare Advisory ( ). 16) Is the continuous care edit still in effect? If so, please provide an update. Currently the continuous care edit is not in effect. 17) What probe edits are planned for the future? NCLOS reviews will continue. Providers exceeding the hospice CAP will also continue to be monitored. 18) In an appeal of a denial, a provider noted that the patient died 6 months after the denied dates of service. The patient was in his first benefit period during the denied dates of service and died his of terminal illness under the care of hospice within 7 months of admission. In the explanation of the unfavorable decision these things were noted: i) The patient appeared stable and chronically ill during the dates under review. ii) Even though he died, there was no evidence of a significant decline to support a terminal prognosis of six months or less for the dates of service in question. iii) The patient s estate was sent a copy of the decision letter, which indicated that even though he died, he was not considered hospice eligible. We would like to know how a patient who died 6 months after the period under review, would not be considered eligible for the hospice benefit, keeping in mind that his attending physician and the hospice medical director certified that in their medical opinion, the patient was eligible at that time. Medicare notes that prognostication is difficult and inexact, and requires there must be sufficient clinical information in the chart to support eligibility in addition to the certification statements. Can you help provide guidance as to what does November 13, 2007 Hospice Coalition Q & A 5

7 constitute clinical and other documentation that support(s) the medical prognosis referred to on page # of Federal Register/Vol.7/ No. 224/Tuesday, Nov 22, 2005/Rules and Regulations. Documentation is imperative to making determinations. The medical record should reflect the information used by the physician in determining the prognosis. Documentation from the IDG should also reflect the condition and status of the beneficiary during their care. Additional information is provided in answer to question #19. Local Coverage Determinations (LCDs) 19) When considering co-morbidities and secondary conditions which help establish guidelines for eligibility, the description from the LCD only indicates that there must exist functional and structural impairments, but does not quantify these. As providers we are left wondering what would constitute a degree of impairment necessary to meet guidelines. Can PGBA provide guidance? Palmetto GBA s approach to policy and education recognizes the importance of continuous quality improvement. Both Palmetto GBA and providers strive to make the best decisions possible, but are often faced with incomplete information despite voluminous documentation. Palmetto GBA s recent policies and educational efforts have highlighted the fact that in order for information to be of value to health care organizations it must allow the end-user to make high quality predictions or decisions. Palmetto GBA has identified insufficient documentation as a major cause of claims denials within the Comprehensive Error Rate testing (CERT) review process. Qualitatively the information currently being collected and reported in support of hospice and palliative care services is often skewed toward prediction (prognostication) at times at the expense of a comprehensive description of the beneficiary s health status and care needs. Palmetto GBA s focus on the qualitative aspects of documentation is intended to promote continuous quality improvement among providers of hospice and palliative care. This approach is especially useful when making semi-structured decisions involving beneficiaries with multiple chronic conditions, for whom information supporting prognostication is often limited. In addition to the revised LCDs Palmetto GBA has published several articles describing its approach. Please see the attached Palmetto GBA articles titled: Going Beyond Diagnosis : The ICF and Decision-Support in Hospice & Palliative Care; Going Beyond Diagnosis : Valuable Information; Going Beyond Diagnosis : Continuous Quality Improvement; November 13, 2007 Hospice Coalition Q & A 6

8 Measurement is a critical piece of continuous quality improvement and requires the collection of relevant data. These data are then used to create information to continuously improve organizational processes, including facilitating semi-structured decisions such as admissions, level of care, re-certifications, and discharge. Whether you re evaluating structure, process, outcomes, or patient/caregiver satisfaction, a standard language is essential when describing the health status of your patient population. That s where the International Classification of Functioning, Disability and Health (ICF) can help. Health care organizations often evaluate the quality of their services by performing utilization review audits. These audits typically focus on high volume/high risk tasks that are critical to the organizational strategic plan. The evaluation often involves the selection of process and/or outcome measures. The selection of the most relevant process or outcome measures may be limited by incomplete clinical documentation. Palmetto GBA s Going Beyond Diagnosis educational initiative is focused on helping health care organizations identify, document, and communicate the unique health care needs of their patients - making it more likely that relevant pieces of data are available to support their quality initiatives. Palmetto GBA Web Site Article Attached 20) The 1994 revision to the New York Heart Association functional capacity classification of heart failure defines Class IV as "Patients with cardiac disease resulting in inability to carry on any physical activity without discomfort. Symptoms of heart failure or the anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort is increased." However, the Palmetto GBA Hospice Heart Disease Local Coverage Determination criteria redefined this as requiring symptoms at rest. Would Palmetto explain how this decision to redefine NYHA Class IV was made? Palmetto GBA s 2001 clarification of NYHA Class IV was made to increase the specificity of the prognostic criteria contained in the Hospice Heart LCD. According to Zipes: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 7th edition, 2005: The Criteria Committee of the New York Heart Association has provided a widely used classification that relates functional activity to the ability to carry out "ordinary" activity. The term ordinary is, of course, subject to widely varying interpretation, as are terms such as undue fatigue that are used in this classification, and this has limited its accuracy and reproducibility. More recently, the New York Heart Association changed its evaluation from functional activity to a broader one, called cardiac status, which takes into account of symptoms and other data gathered from the patient. Cardiac status is classified as (1) uncompromised, (2) slightly compromised, (3) moderately compromised, and (4) severely compromised. November 13, 2007 Hospice Coalition Q & A 7

9 Palmetto GBA s current draft LCD addressing Cardiopulmonary Conditions recognizes the limitations of the NYHA Classification and acknowledges that the clinical community s understanding and approach to heart failure, its etiologies, evaluation and treatment, has evolved much over the past 10 years. According to Zipes: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 7th edition, 2005: Heart failure is a principal complication of virtually all forms of heart disease. An American College of Cardiology/American Heart Association (ACC/AHA) Task Force on Practice Guidelines described this condition as follows. Heart failure is a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood. The cardinal manifestations of heart failure are dyspnea and fatigue, which may limit exercise tolerance, and fluid retention, which may lead to pulmonary congestion and peripheral edema. Both abnormalities can impair the functional capacity and quality of life of affected individuals, but they do not necessarily dominate the clinical picture at the same time. Because not all patients have volume overload at the time of initial or subsequent evaluation, the term "heart failure" is preferred over the older term "congestive heart failure. The American College of Cardiology/American Heart Association guidelines on the evaluation and management of heart failure set forth a staging system (see table listing Stages of Heart Failure) This staging system recognizes that there are established risk factors and structural prerequisites for the development of heart failure, that therapeutic interventions that are initiated before the onset of left ventricular dysfunction or symptoms can reduce morbidity and mortality, that patients generally progress from one stage to the next unless disease progression is slowed or stopped by treatment, and that all patients benefit from risk factor modification including blood pressure control, lipid management, exercise training, and smoking and alcohol cessation. Palmetto GBA s draft Hospice LCD addressing Cardiopulmonary Conditions is attached along with an example of how the ICF can be used to identify relevant domains and categories for incorporation into the clinical documentation. The identified domains and categories would help structure and organize narrative (data) that would then be available to create information that would support both predictions and decisions. Stages of Heart Failure Stage Description Examples At high risk for developing HF because of the A presence of conditions that are strongly associated Systemic hypertension with the development of HF Coronary artery disease Diabetes mellitus November 13, 2007 Hospice Coalition Q & A 8

10 Stage Description B C D No identified structural or functional abnormalities of the pericardium, myocardium, or cardiac valves No history of signs or symptoms of HF Presence of structural heart disease that is strongly associated with the development of HF No history of signs or symptoms of HF Current or prior symptoms of HF associated with underlying structural heart disease Advanced structural heart disease and marked symptoms of HF at rest despite maximal medical therapy Require specialized interventions HF = heart failure. Examples History of cardiotoxic drug therapy History of alcohol abuse Family history of cardiomyopathy Left ventricular hypertrophy or fibrosis Left ventricular dilation or dysfunction Asymptomatic valvular heart disease Previous myocardial infarction Dyspnea or fatigue due to left ventricular systolic dysfunction Asymptomatic patients receiving treatment for prior symptoms of HF Frequent HF hospitalizations and cannot be discharged In the hospital awaiting heart transplant At home with continuous inotropic or mechanical support In hospice setting for management of HF Adapted from Hunt SA, Baker DW, Chin MH, et al: ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult: Executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1995 Guidelines for the Evaluation and Management of Heart Failure). Circulation 104:2996, ) Reisberg's Functional Assessment Staging (FAST) scale was developed as a research tool that describes the typical progression of dementia in Alzheimer s disease. This instrument predates much of what has been learned about dementing illnesses over the past two to three decades. The FAST is now almost never used in clinical practice and does not describe the typical progression of non-alzheimer s dementia patients, which represent over 1/3 of all dementia sufferers. Please explain the rationale for continuing to use this dated instrument in November 13, 2007 Hospice Coalition Q & A 9

11 the Hospice Alzheimer s Disease and Related Conditions Local Coverage Determination criteria. Within the context of Palmetto GBA s Hospice LCD for Hospice Alzheimer s Disease & Related Disorders, the FAST scale is used to help providers describe the observed activity limitations. The importance of this task is addressed in the opening paragraph of the LCD: Alzheimer s Disease and related disorders may support a prognosis of six months or less under many clinical scenarios. The identification of specific structural/functional impairments, together with any relevant activity limitations, should serve as the basis for palliative interventions and care planning. The structural and functional impairments associated with a primary diagnosis of Alzheimer s Disease are often complicated by comorbid and/or secondary conditions. Comorbid conditions affecting beneficiaries with Alzheimer s Disease are by definition distinct from the Alzheimer s Disease itselfexamples include coronary heart disease (CHD) and chronic obstructive pulmonary disease (COPD). Secondary conditions on the other hand are directly related to a primary condition in the case of Alzheimer s Disease examples include delirium and pressure ulcers. The important roles of comorbid and secondary conditions are described below in order to facilitate their recognition and assist providers in documenting their impact. The Reisberg Functional Assessment Staging (FAST) Scale has been used for many years to describe Medicare beneficiaries with Alzheimer s Disease and a prognosis of six months or less. The FAST Scale is a 16-item scale designed to parallel the progressive activity limitations associated with Alzheimer s Disease. Stage 7 identifies the threshold of activity limitation that would support a six-month prognosis. The FAST Scale does not address the impact of comorbid and secondary conditions. These two variables are thus considered separately by this policy. 22) In reviewing the draft LCD for Hospice Cardiopulmonary Conditions (DL26377), it is difficult to understand how Palmetto or providers can use this to make a determination. It basically says that if you have sufficient structural and functional cardiopulmonary changes, with or without secondary or co-morbid conditions, such that most people's prognosis is likely to be six months or less - that individual is hospice eligible. While we welcome the ability to utilize clinical expertise to determine prognosis, we are concerned that these less prescriptive LCDs will allow for increased denials of eligible patients. Can PGBA provide hospices more guidance? CAP Please see response to question # ) Please provide the most current CAP assessments. Palmetto GBA is scheduled to complete 1,146 Hospice CAP and Inpatient Day Limitation Calculations for the 2006 CAP Period. At the end of October 2007, we had completed 386 Hospice CAP calculations. We have completed about 33.7% of the hospices scheduled for completion. Of those Hospice CAPs completed, we have November 13, 2007 Hospice Coalition Q & A 10

12 identified 67 providers that exceeded the Aggregate CAP Amount and 2 providers that exceeded the Inpatient Day Limitation (IDL) calculation. Provider Notification Letters have been issued to all of these providers. 24) In your meetings with CMS regarding the cap do you have any indication that CMS is requiring the other RHHIs to calculate Cap in the same manner as Palmetto GBA? Are there other pearls of wisdom you can disclose regarding those conversations? CMS does not disclose or discuss the content of their conversations with other RHHIs to Palmetto GBA. 25) Can you give us an update on the CAP corrective action activity, states involved, number of programs involved, education begin provided to those involved programs, etc.? ] OK and MS providers that exceeded the hospice CAP are being monitored. Corrective actions plans have been reviewed and follow up review will be initiated during FY Approximately 50 providers are involved between the two states. 26) Please give us an update on the 06 Cap demand letters. How many of Palmetto's Hospices have been reviewed thus far? How many Cap demand letters have been sent out thus far? How many of the Hospices receiving 06 demand letters thus far exceeded the cap for the first time in 06? See answer to question #23. We do not keep track of Hospice provider s first time wherein they exceeded the Aggregate CAP Amount. CR5567 Reporting Additional Data on Claims 27) How do we report routine nursing visits in agency owned inpatient facilities? There was not enough information to provide input. However, billing instructions are provided in the change request and the attached Med Learn Matters article (Attachment E). 28) We do not currently capture attending physician visit date/time are they going to be required to document this for hospice billing? Providing physician s date of visits, HCPCS code and documentation is still a requirement. Instructions on the new changes is provided in the change request and in the attached Med Learn Matters article (Attachment E). 29) What is the responsibility of the hospice to report physicians and nurse practitioner services that are not provided by the hospice? Hospice agencies are only required to report and/or bill physician and nurse practitioner [(NP) if the NP is acting as the patient s attending physician] services that are provided by the hospice agency. In other words, if the physician or NP (acting as the November 13, 2007 Hospice Coalition Q & A 11

13 attending physician) is not employed by or on contract with the hospice agency, then those services are not required to be reported on the claim. 30) How will attending physician visits be counted and reported with HCPCS? For each week beginning on Sunday and ending on Saturday, hospice providers are to indicate the number of services/visits provided by nurses (registered, licensed and /or nurse practitioner), home health aides, social workers, physicians, and nurse practitioners serving as the beneficiary s attending physician. A service/visit constitutes direct care to the beneficiary. An entry in a medical/clinical record without a visit does not constitute a visit and as such is not counted. Rounds in facilities do not constitute a visit. Only the number of direct patient care visits is counted. To be counted a service/visit must be medically reasonable and necessary. This applies in circumstances where there is separate billing for a physician or nurse practitioner, serving as the attending physician. Attending physician services and nurse practitioners serving as the beneficiary s attending physician will be reported with the 0657 revenue code and should be individually dated, reporting the date that each HCPCS code was delivered. Q codes are not required with the 0657 revenue code. Additionally, reporting of modifier GV is required with revenue code 0657 when billing physician services performed by a nurse practitioner. The method for reimbursement of attending physician services has not changed. Reference: CMS Change Request ) What will we do about the time of death? Should we count a visit when the hospice receives a call after the death of a patient and the nurse goes out to make the call to the MD to pronounce the death will this be considered medically necessary? To constitute a visit, the discipline, (as defined above) must have provided direct care to the beneficiary. For example, phone calls, documentation in the medical/clinical record, interdisciplinary group meetings, obtaining physician orders, rounds in a facility or any other activity that is not directly related to the provision of items or services to a beneficiary, does not count towards a visit to be placed on the claim. In addition, the visit must be medically reasonable and necessary for the provision of care required by the beneficiary. 32) How will the current bill reflect multiple venues of care in the same day routine home care visit in the am and GIP location and care in the pm of the same day? This was sent to CMS for further clarification. 33) If a patient is on Continuous Care, will we able to count the visit the primary care team makes while the continuous care nurse is in the home? 0652 revenue code billing has not changed. Providers would still bill in 15 minute increments and breakout the nursing visit as one line item and any other disciplines in the home would be a separate line item. Official billing instructions are provided in the change request and the attached Med Learn Matters article (Attachment E). November 13, 2007 Hospice Coalition Q & A 12

14 34) What about the visit that starts at 11:30 pm on Saturday night and ends on Sunday at 12:30 am. How would you count this visit? As outlined in Change Request 5567, hospice agencies will report the number of direct patient care visits made by the designated staff (nurses, home health aides, and social workers) each week beginning on Sunday and Ending on Saturday. The length of time the individual spends with the patient is not relevant to counting the visits. The visit is counted for the day on which the staff arrived at the patient s home. Therefore, in this case, if the staff did not leave and come back during the hours of 11:30 pm and 12:30 am, one visit is counted for Saturday. 35) Do we have any information about the charge structure? Charges for the service revenue codes of 055X, 056X, and 057X are decided by the hospice. Charges are placed in the covered charges locator on the bill. Medicare systems will change any charges and units associated with 055X, 056X and 057X revenue codes to be non-covered. Providers will notice that once the claim processes, the charges that they entered as covered will now appear in the non-covered column. For nurses, home health aides and social workers, the weekly total of services/visits by discipline are not for the purpose of separate payment but to provide transparency into the services that are being provided beneficiaries who are electing the Medicare hospice benefit. Hospice payment to the provider continues to be based on the level of care revenue codes. Reference: CMS Change Request ) Will PGBA be providing any additional training? Palmetto GBA conducted an Ask the Contractor Teleconference (ACT) regarding the 2008 Hospice Billing Changes on October 22 at 2 p.m. EST. and conducted a Centra online session on October 25 at 10 a.m. EST. The Centra class was recorded and can be played back for those providers that were unable to attend. The ACT call was attended by over 400 providers and the minutes and transcript is posted on the Palmetto GBA Web Site at under RHHI and ACT. The 2008 RHHI workshop series will include information on the new changes. 37) Will PGBA be ready to accept these new claims? Palmetto GBA will be ready to accept the requirements stated in CR ) The Hospice Benefit is described throughout numerous documents (Social Security language, Federal Statute, Medicare COPs, etc.) as providing services to the patient and family through an interdisciplinary team. Also, in describing the care provided from a hospice to a patient and the family, it occurs from a very broad and holistic philosophy of care, encompassing the physical, psychosocial, emotional and spiritual domains. This philosophy is embedded throughout the language as indicated above. Considering the philosophy hospice is built upon, the language within the benefit as defined by Medicare, it has a much broader November 13, 2007 Hospice Coalition Q & A 13

15 approach to providing health and health care than an acute medically directed practice. This broader focus of hospice, as well as the interdisciplinary approach to care, indicates that medically necessary and reasonable also be defined in a broader philosophy of care than the acute care, event oriented model, that portrays the majority of our health care system. How does Palmetto or CMS determine medically necessary related to a hospice visit? The transmittal listed provides an example of the information being requested. This question was also submitted to CMS for any additional information that may be provided. NOTE: Transmittal 1372, dated November 2, 2007 rescinds and replaces Transmittal 1304 dated July 20, 2007, to have the reporting be optional effective January 1, 2008, and not mandatory until July 1, All other material remains the same. Does the person making the visit somehow mark this on the note or does billing just assume the visit is medically necessary? According to change request 5567 it is up to the individual provider to put a process in place to track individual visits. An example is given in the change request. Or is it a covered medically necessary visit if it is on the care plan? Is providing comfort medically necessary? Is providing comfort to a patient and/or a family in crisis, through psychosocial interventions with a physician; a nurse; a social worker; a counselor; a chaplain; a volunteer medically necessary? Is it reasonable when these interactions maintain an environment of comfort, calmness, understanding, empathy, support the grieving process, relieve fears, lower restlessness and agitation? This was sent to CMS for further clarification. Help us understand whether or not a shift is occurring by CMS in the fundamental consideration of what is medically necessary and reasonable for a hospice patient and the care they receive as well as the support the family is to receive under the benefit. Palmetto GBA is not aware of any shift occurring by CMS in the consideration of what is medically necessary and reasonable for a hospice patient. 39) How do we count visits turned in by staff members? Do we pull a chart every week or audit a chart weekly (since all the notes from all disciplines are in one location, the chart) and turn in the # of visits to billing? It is up to the provider to determine how this will be tracked and reported. 40) CR 5567, please attach a UB billing sample showing how charges are made? The CR instructions intentionally provide hospices with flexibility and discretion in reporting, in an effort to reduce provider burden. For example weekly service reporting of revenue codes 055X, 056X, and 057X may be accompanied by weekly reporting of level of care revenue codes of and However, another option might be November 13, 2007 Hospice Coalition Q & A 14

16 to first report all the level of care revenue codes for the month, followed by the service revenue codes. Such flexibility may be of value to providers and vendors in order to meet the administrative needs of the agency. Discretion to choose different reporting options is allowed as long as the options are not in conflict with the instructions in the CR. We have provided 2 possible options for providers. In this first option, you can see by the service dates that we ve just moved chronologically through the month of August week by week. Dollar signs ($$$) represent reimbursement to the provider. This has not changed and remains the way in which the provider is paid. The Xs indicate charges decided by the provider. By Calendar Rev. HCPCS Serv. Date Serv. Total Charges Cd. Units 0651 Q $$$.$$ xxx.xx xx.xx xxx.xx 0651 Q $$$.$$ xx.xx xxx.xx xxx.xx xxx.xx xx.xx xxx.xx xxx.xx total all revenue codes ***DISCLAIMER: The above data is NOT intended to be an absolute way of submitting the required data on a claim. It is intended only for the purpose of showing you a possible option of how you might enter data on a claim. This is another option of the same month of billing. But in this option, we ve grouped the LOC revenue codes at the beginning and then lined up groupings of service revenue codes. FISS will see this as logical and the claim will process. Other options that follow this same line of logic are allowed. November 13, 2007 Hospice Coalition Q & A 15

17 By Revenue Code Rev. HCPCS Serv. Date Serv. Total Charges Cd. Units 0651 Q $$$.$$ 0651 Q $$$.$$ xxx.xx xxx.xx xxx.xx xxx.xx xx.xx xx.xx xxx.xx xx.xx xxx.xx total all revenue codes ***DISCLAIMER: The above data is NOT intended to be an absolute way of submitting the required data on a claim. It is intended only for the purpose of showing you possible options of how you might enter data on a claim. 41) Do the visit charges have to be included in the total amount billed each month? If so, this is a real financial burden on the billing department that will have to do massive AR adjustments monthly. We will have to adjust non-covered charges off the AR. Yes. Change Request 5567, specifically states providers are to enter the charges for the service revenue codes (55X, 56X, and 57X) in the covered charges field. When the processing of a claim has been completed, the provider will see on their remittance advices (RA) that the charges were moved to the non-covered charges field. Thus, providers should talk with their software vendors to determine what is best for their agency as to how their claims submission software should be set up. 42) Give and overview of the new changes in reporting based on the location of where the patient receives care (CR 5670)? Medicare claims for all levels of care, including inpatient hospice levels of care, will be wage adjusted using the CBSA for the location where services are furnished. Payment calculations for revenue codes 0651 and 0652 (Routine Home Care and Continuous Home Care) are not changed, as these levels of care are currently wage adjusted by the location where services are furnished. Providers are to continue using Value Code 61 with the CBSA code for the beneficiary s place of residence. The definition of Value Code 61 has been updated in order to make it clear that the CBSA code used with Value Code 61 indicates place of residence where the home health or hospice service is delivered. For revenue codes 0655 and 0656 (Inpatient Respite and General Inpatient Care), the CBSA code on the provider file will no longer be used in payment calculations. The CBSA for inpatient levels of care shall be reported using Value Code November 13, 2007 Hospice Coalition Q & A 16

18 G8, for services provided on or after January 1, Value Code G8 is defined as the CBSA of the facility where inpatient hospice service is delivered. Value Codes 61 and G8 can be reported on the same monthly bill. If different locations have occurred during the same billing period for either Value Code 61 or G8 or both, the last CBSA code for the billing period is to be reported. Reference: CMS Change Request 5670: MAC 43) Please provide an update on the MAC process. To be discussed by Neal Burkhead at 3 p.m. 44) What will the process be for a multi-state provider to be able to work with one MAC? To be discussed by Neal Burkhead at 3 p.m. 45) How will the changes in the MACs be communicated? How long with the transition be? To be discussed by Neal Burkhead at 3 p.m. 46) Can Palmetto tell us which regions they have applied for? To be discussed by Neal Burkhead at 3 p.m. November 13, 2007 Hospice Coalition Q & A 17

19 ATTACHMENT A - CAP Information by State State Code & State Alabama Arizona Arkansas Calofornia Colorado Delaware Florida Georgia Illinois Indiana Kentucky Louisiana Massachusetts Michigan Mississippi North Carolina Ohio Oklahoma Pennsylvania South Carolina Tennessee Texas Utah Virginia Total Hospices Hospices Hospices Completed With O/P Percent of O/P To Completed 42.4% 50.0% 0.0% 0.0% 0.0% 0.0% 0.0% 10.3% 9.8% 2.2% 4.3% 0.0% 7.7% 0.0% 0.0% 75.0% 0.0% 33.0% 20.0% 100.0% 16.7% 28.6% 0.0% 22.2% 0.0% 12.5% 50.0% 0.0% 0.0% Overpayment Amounts Caps IDL $29,286, $5,157, $0.00 $0.00 $0.00 $0.00 $0.00 $4,211, $2,323, $533, $102, $407, $0.00 $617, $0.00 $0.00 $7,217, $0.00 $260, $801, $647, $1,538, $2,198, $0.00 $1,581, $0.00 $2,330, $147, $0.00 $ $58,830, $533, Grand Total Overpayment $59,363,281.00

20 Case Scenario CS #01.Cardiopulmonary.2008 CR is an 85 year old male admitted to hospice five months prior to this review. He was referred to hospice following an acute inpatient hospitalization for pneumonia, delirium, and dehydration. The hospice medical record identified ICD-9-CM (congestive heart failure, unspecified) as the terminal diagnosis. Hypertension, atrial fibrillation, and aortic stenosis were listed as comorbid conditions. CR s CHF was diagnosed 2-3 years prior to the hospice admission and manifested as increased dyspnea with minimal exertion. CR was prescribed a walker to help him ambulate, however, he prefers to ambulate without it. CR lives with a daughter on the ground floor of a three-story apartment building. Admission Palliative Performance Scale (PPS) score was 50%. The nursing evaluation during this review period documented increasing frequency of dyspnea and chest pain, with concomitant increased use of oxygen and pronounced bilateral lower extremity edema. The daughter reported that he frequently drives himself to a local diner where he meets friends and likely eats foods that he should not be eating. CR s daughter also reported that he s been complaining of chest tightness at bed time which he denies. The medical record documents that CR s lasix dose was increased to 40 mg daily and a trial of sublingual nitroglycerin was prescribed for the chest tightness. Review of other supporting medical documentation, including the acute inpatient hospital admission history and physical, revealed that a) 2 ½ years prior to this review period CR had a cardiac echo showing critical aortic stenosis aortic valve area = 0.7 cm2 with concentric left ventricular hypertrophy, moderately depressed left ventricular systolic function, moderate global hypokinesis, mild left atrial enlargement and mild mitral regurgitation b) the atrial fibrillation was first identified 10 months prior to the current review period and c) CR suffers from insomnia and sleeps in a recliner. CR declined aortic valve replacement surgery. Description of scenario using ICD-9-CM: Congestive Heart Failure, unspecified Comorbid Conditions 401 Hypertension Atrial Fibrillation Aortic valve stenosis Chronic ischemic heart disease, unspecified Insomnia due to medical condition classified elsewhere Description of scenario using the ICF: ICF Component: Body Functions and Structures ICF Domain: Mental function Global mental function b130 Energy and drive functions b1302 Appetite b134 Sleep functions b1340 Amount of sleep Palmetto GBA

21 Case Scenario b1343 Quality of sleep ICF Domain: Sensory functions and pain Pain b280 Sensation of pain b28011 Pain in chest ICF Domain: Functions of the cardiovascular, hematological, immunological and respiratory systems Functions of the cardiovascular system b410 Heart functions b4101 Heart rhythm b4102 Contraction force of ventricular muscles b4103 Blood supply to the heart Additional functions and sensations of the cardiovascular and respiratory system b455 Exercise tolerance functions b4550 General physical endurance b460 Sensations associated with cardiovascular and respiratory functions (tightness of the chest and dyspnea) ICF Domain: Structures of the cardiovascular, immunological and respiratory systems ICF Component: Activities and Participation ICF Domain: Mobility s410 Structures of cardiovascular system s4100 Heart s41000 Atria s41008 Structure of heart, aortic valve Walking and moving d450 Walking Moving around using transportation d475 Driving ICF Domain: Interpersonal interactions and relationships Particular interpersonal relationships d750 Informal social relationships 2 Palmetto GBA 2008

22 Case Scenario d7500 Informal relationships with friends ICF Domain: Community, social and civic life d920 Recreation and leisure d9205 Socializing ICF Component: Environmental Factors ICF Domain: Products and Technology e120 Products and technology for personal indoor and outdoor mobility and transportation e1201 Assistive products and technology for personal indoor and outdoor mobility and transportation ICF Domain: Support and relationships e310 Immediate family ICF Domain: Services, systems, and policies e580 Health services, systems, and policies e5802 Health policies Palmetto GBA

23 Going Beyond Diagnosis Using ICF Worksheet ICF Components Description/Disability Intervention(s) Outcome Body Functions b1302 b1340 b1343 b28011 b4101 b4102 b4103 b4550 b460 Body Structures s41000 s41008 Activities and Participation d450 d475 d7500 d9205 Environmental Factors e1201 e310 e450 e5802 Medical Review Determination: Copyright 2007, Palmetto GBA. All Rights Reserved.

24 ATTACHMENT D - Redetermination/Appeals Report Hospice Reversal Rate Fourth Quarter FY 07 Quarter Total Percent Totals by State State Redeterminations QIC ALJ Autodeny Affirmed Dismissed Reversed Affirmed Dismissed Reversed Affirmed Dismissed Reversed AL Redetermination Cases July Aug Sept AR Affirmed % FL Dismissed % Reversed (Partial or Complete) % Total Cases QIC Cases July Aug Sept Affirmed % GA IL IN KY LA MS Dismissed % NC Reversed (Partial or Complete) % Total Cases ALJ Cases July Aug Sept Affirmed % NM OH OK SC TN Dismissed % TX Reversed (Partial or Complete) % Total Cases

25 MLN Matters Number: MM5567 Revised Related Change Request (CR) #: 5567 Related CR Release Date: December 18, 2007 Effective Date: January 1, 2008 (optional); July 1, 2008 (mandatory) Related CR Transmittal #: R1397CP Implementation Date: January 7, 2008 Reporting of Additional Data to Describe Services on Hospice Claims Note: This article was revised on December 26, 2007, to reflect that CMS revised CR5567. The CR transmittal date, transmittal number, and Web address for accessing CR5567 were changed. Previously, this article was revised on November 2, 2007 to amend the effective date for mandatory reporting by hospices. The mandatory reporting date for these changes is July 1, As of January 1, 2008, hospices have the option to begin reporting the data. These changes were made as CMS re-issued CR5567 on November 2. All other information remains the same. Provider Types Affected Provider Action Needed Hospices billing Medicare regional home health intermediaries (RHHIs) for hospice services provided to Medicare beneficiaries. STOP Impact to You This instruction, Change Request (CR) 5567, requires hospices to report an expanded level of claims data for Medicare payments that describe the services provided in the course of delivering each hospice level of care billed. CAUTION What You Need to Know CR 5567 provides instructions for the expansion of required data on hospice claims. GO What You Need to Do Make certain that your billing staffs are aware of these changes as listed in the Key Points below and in the revisions to the Medicare Claims Processing Manual chapter 11, sections 30.1 and The revised manual sections are attached to Disclaimer This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. Page 1 of 4