The Medicare Hospice Program: New Billing Requirements & Hot Topics from Your Medicare New England Home Care & Hospice Conference and Trade Show

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Jodie Jennings
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has produced this material as an informational reference for providers furnishing services in our contract jurisdiction.

1 The Medicare Program: New Billing Requirements & Hot Topics from Your Medicare New England Home Care & Conference and Trade Show Add doc ctrl no. Today s Presenters Corrinne Ball, RN, CPC, CAC, CACO Provider Outreach and Education Consultant J6.provider.training@anthem.com 2 Disclaimer National Government Services, Inc. has produced this material as an informational reference for providers furnishing services in our contract jurisdiction. National Government Services employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this material. Although every reasonable effort has been made to assure the accuracy of the information within these pages at the time of publication, the Medicare Program is constantly changing, and it is the responsibility of each provider to remain abreast of the Medicare Program requirements. Any regulations, policies and/or guidelines cited in this publication are subject to change without further notice. Current Medicare regulations can be found on the CMS website at 3 1

2 No Recording Attendees/providers are never permitted to record (tape record or any other method) our educational events This applies to our webinars, teleconferences, live events and any other type of a National Government Services educational event 4 Agenda CR8877 Principal diagnosis Q5003/Q5004 NOEs Notice of Election Termination/Revocations (NOTR) CR9114 Beneficiary NOE attending physician Beneficiary NOE timely filing Medical review data Resources 5 CR8877 Issued on August 22, 2014 Effective for dates of service on or after October 1, 2014 claims with through dates on or after 10/01/2014; and NOEs with from dates on or after 10/01/

3 Principal Diagnosis Claims with the following listed as the principal diagnosis will be returned for a more definitive hospice diagnosis based on ICD-9-CM/ICD-10-CM Coding Guidelines Debility (799.3, /R53.81) Adult failure to thrive (783.7/R62.7) Several dementia ICD-9-CM/ICD-10-CM codes Most are found under the ICD-9-CM/ICD-10-CM classification, Mental, Behavioral, and Neurodevelopmental Disorders See Attachment A within CR Principal Diagnosis Unspecified codes are only to be used when the medical record, at the time of the encounter, is insufficient to assign a more specific code. However, it is recognized that the underlying neurologic condition causing dementia may be difficult to code because the medical record may not provide sufficient information. There are codes listed under Diseases of the Nervous System that do provide for appropriate principal code selection under those circumstances and hospice providers are encouraged to look at the coding conventions under that classification for coding dementia conditions on hospice claims. MACs cannot tell providers what specific codes to use 8 Q5003/Q5004 Clarification on the use of Q5003/Q5004 Does not represent a change in policy regarding the correct usage of Q5003 and Q5004 Q5004 shall be used for hospice patients in a SNF, or hospice patients in the SNF portion of a dually-certified nursing facility (see next side for Q5004 criteria) If a beneficiary is in a NF but doesn t meet the criteria for Q5004, the site shall be coded as Q5003, for a long term care nursing facility 9 3

4 Q5003/Q5004 There are 4 situations where Q5004 is appropriate: If the beneficiary is receiving hospice care in a solely-certified SNF; If the beneficiary is receiving general inpatient care in the SNF; If the beneficiary is in a SNF receiving SNF care under the Medicare SNF benefit for a condition unrelated to the terminal illness and related conditions, and is receiving hospice routine home care; this is uncommon; OR, If the beneficiary is receiving inpatient respite care in a SNF. 10 NOEs NOEs shall be filed within 5 calendar days after the hospice admission date To be timely, the NOE must have a receipt date within 5 calendar days after the hospice admission date, AND the NOE must subsequently process and finalize in status/location P B Timely NOE Example A patient is admitted on October 8, 2014 NOE is submitted on October 13, 2014 and processes on October 17, 2014 To be timely, the NOE must have a receipt date of October 13, 2014; and the NOE must subsequently process (P B9997) 12 4

5 NOEs In instances where an NOE is not timely-filed, Medicare will not pay for the days of hospice care from the hospice admission date to the date the NOE is submitted and accepted Reported as noncovered on the claim with an OSC 77 These noncovered days are provider liable, and beneficiary cannot be billed for the noncovered days 13 Untimely NOE Example A patient is admitted on October 8, 2014 NOE is submitted on October 13, 2014 and is returned to the provider (RTP d) on October 14, 2014 due to a billing error The NOE is resubmitted on October 17, 2014 and ultimately processes on October 21, 2014 This is an untimely NOE Special Billing Requirements for the claim: The OSC 77 is reported along with the dates associated with the late NOE (10/08/ /16/2014), and the revenue code lines associated with the OSC 77 dates are reported as noncovered 14 Claim Reporting Example for Untimely NOE: Claim Page One 15 5

Claim Reporting Example for Untimely NOE: Claim Page Two 16 Timely NOE Exceptions If a hospice fails to file a timely-filed NOE, it may request an exception which, if approved, waives the

6 Claim Reporting Example for Untimely NOE: Claim Page Two 16 Timely NOE Exceptions If a hospice fails to file a timely-filed NOE, it may request an exception which, if approved, waives the consequences of filing an NOE late 17 Timely NOE Exceptions The four circumstances for a possible exception are as follows: 1. Fires, floods, earthquakes, or other unusual events that inflict extensive damage to the hospice s ability to operate; 2. An event that produces a data filing problem due to a CMS or Medicare contractor systems issue that is beyond the control of the hospice 18 6

7 Timely NOE Exceptions 3. A newly Medicare-certified hospice that is notified of that certification after the Medicare certification date, or which is awaiting its user ID from its Medicare contractor; OR, 4. Other circumstances determined by the Medicare contractor or CMS to be beyond the control of the hospice. Example: submits NOE timely, but the NOE cannot be processed due to sequential billing as the previous hospice has not finished their billing 19 Timely NOE Exceptions Exceptional circumstance requests still need to be submitted following the OSC 77 late NOE requirements In addition, report a KX modifier with the Q HCPCS code reported on the earliest dated level of care line on the claim; AND Enter remarks explaining the reason for the exception request 20 Late NOE Exception Remarks For fires, floods, earthquakes, or other unusual events that inflict extensive damage to the hospice s ability to operate Remarks must state Late NOE due to unusual event For an event that produces a data filing problem due to a CMS or Medicare contractor systems issue that is beyond the control of the hospice Remarks must state Late NOE due to data filing problem 21 7

8 Late NOE Exception Remarks For a newly Medicare-certified hospice that is notified of that certification after the Medicare certification date, or which is awaiting its user ID from its Medicare contractor Remarks must state Late NOE due to newly certified Medicare hospice For any other circumstances determined by the Medicare contractor or CMS to be beyond the control of the hospice Please state the reason for the late NOE If the late NOE is due to sequential billing either with your own facility (e.g., the patient revokes and re-elects the benefit within a few days) or with another facility Remarks must state Late NOE due to sequential billing 22 Late NOE Exception Remarks You may add additional remarks to further explain the late NOE, but please start all remarks with the statements previously mentioned based on your situation. 23 Timely NOE Exceptions The KX modifier prompts the MAC to review the remarks to determine if a request for additional documentation is required Late NOEs due to sequential billing won t require additional documentation. Once remarks are reviewed and it s determined late NOE is due to sequential billing, the MAC will approve the exception The MAC will process the claim and remove the submitted provider liable days» Allow payment for the days associated with the late-filed NOE 24 8

9 Timely NOE Exceptions Any other reason will initiate a nonmedical documentation request Upon receiving the documentation request, providers will send any documentation supporting the request for an exception 25 Timely NOE Exceptions Based on the documentation, the MAC shall determine is there is a qualified exception If the request for an exception is approved by the MAC: The MAC will process the claim and remove the submitted provider liable days Which will allow payment for the days associated with the late-filed NOE If the MAC finds that the documentation does not support allowing an exceptional circumstance The MAC shall process the claim as submitted 26 Exception NOE Example Patient is admitted on October 8, 2014 NOE is submitted on October 10, 2014 and RTPs on October 12, 2014 due to sequential billing NOE is resubmitted on October 28, 2014, after the previous hospice finishes their billing, and ultimately processes on November 1,

Exception NOE Example Special Billing Requirements: The OSC 77 is reported on the claim along with the dates associated with the late NOE (10/08/2014-10/27/2014), and the revenue code lines

10 Exception NOE Example Special Billing Requirements: The OSC 77 is reported on the claim along with the dates associated with the late NOE (10/08/ /27/2014), and the revenue code lines associated with the OSC 77 dates are reported as noncovered In addition, the first level of care revenue line associated with the late NOE will be reported with a KX modifier next to the site of service HCPCS code (location Q code). 28 Claim Reporting Example for Exception: Claim Page One 29 Claim Reporting Example for Exception: Claim Page Two 30 10

11 Claim Reporting Example for Exception: Claim Page Four 31 Did You Know? Overlap Disputes If the system does not allow you to submit NOE/claims due to another provider s open benefit period in CWF, you can call the Provider Contact Center for assistance First, always try to work it out with the other provider Document contact attempts Then, if all attempts to work it out with the other provider fail, call the Provider Contact Center and state that you have a CWF hospice dispute 32 NOE Submission Log into FISS/DDE and access the FISS Main Menu Key 02 in the ENTER MENU SELECTION field and <Enter> Key 49 in the ENTER MENU SELECTION field and <Enter> INST Claim Entry Menu will be displayed 33 11

12 NOE Claim Page One Field HIC TOB NPI STMT DATES FROM PATIENT DATA ADMIT DATE OCC CDS/DATE FAC. ZIP Description/Valid Values Enter the beneficiary s HICN 81A (Freestanding hospice: system generated) 82A (Hospital-based hospice: provider keyed) Enter the NPI associated with the OSCAR number Enter the date of the hospice election in the MMDDYY format Enter the beneficiary s last name, first name, date of birth (MMDDCCYY), full mailing address, ZIP code, and gender Enter the date of the hospice election in the MMDDYY format. (Note: The ADMIT DATE and the STMT DATES FROM date should match.) Enter occurrence code 27 along with the date of certification in the MMDDYY format Enter the facility ZIP code of the provider 34 NOE Claim Page Three Field RI Description/Valid Values Enter the release of information indicator. Valid values are: Y to indicate you have a signed statement on file R to indicate the release is limited or restricted N to indicate there is no release is on file DIAGNOSIS Enter the hospice diagnosis code, including all five digits where applicable CODES ATTENDING Enter the NPI and the name of the attending physician designated by the PHYS NPI/LN/FN patient at the time of election as having the most significant role in the determination and delivery of the patient s medical care.* OTHER PHYS NPI/LN/FN Enter the NPI and the name of the hospice physician responsible for certifying/recertifying that the patient is terminally ill if the certifying physician differs from the attending physician. Note: For electronic claims, this is reported in Loop ID 2310F - Referring Provider Name *If there is no attending physician, enter the certifying physician in this field. 35 NOTRs If a hospice patient is discharged alive or revokes the election of hospice care, hospices must file an NOTR within 5 calendar days after the discharge/revocation s continue to have 12 months from the date of service in which to file their claims timely 36 12

13 NOTRs To be timely, the NOTR must have a receipt date within 5 calendar days after the hospice discharge/revocation date Unless the hospice has already filed a final claim NOTRs are NOT submitted for hospice transfers or death There is currently no financial impact if NOTRs are not filed timely; therefore, there is no special coding required for late NOTRs 37 NOTR Notes Submission of the NOTR will NOT prevent the final claim from processing Purpose of the NOTR is to ensure that the CWF is updated quickly so other providers may begin to bill Medicare for services Give the hospice providers time to gather all of the information in order to submit a complete final claim 38 NOTR Notes NOTR is NOT submitted if the patient dies or transfers to another hospice NOTR is only used for live discharges from the Medicare hospice benefit or revocations NOTR is NOT submitted if the hospice submits the final claim within 5 calendar days after the date of discharge/revocation 39 13

14 NOTR Examples Timely NOTR Patient revokes the hospice benefit on October 8, The NOTR is submitted on October 13, 2014 and ultimately processes on October 17, 2014 Untimely NOTR Patient revokes the hospice benefit on October 8, The NOTR is submitted on October 13, 2014 and is returned to the provider (RTP D) on October 14, 2014 due to a billing error NOTR is resubmitted on October 17, 2014 and ultimately processes on October 21, 2014 No special coding required if the NOTR is not submitted timely 40 NOTR Submission Log into FISS/DDE and access the FISS Main Menu Key 02 in the ENTER MENU SELECTION field and <Enter> Key 49 in the ENTER MENU SELECTION field and <Enter> INST Claim Entry Menu will be displayed 41 NOTR Claim Page One Field HIC TOB NPI STMT DATES FROM Description/Valid Values Enter the beneficiary s HICN 81B (Freestanding hospice: provider keyed) 82B (Hospital-based hospice: provider keyed) Enter the NPI associated with the OSCAR number Enter the start date of the hospice benefit period in which the discharge or revocation is effective in MMDDYY format. STMT DATES TO Enter the date of discharge or revocation in MMDDYY format

15 NOTR Claim Page One Field PATIENT DATA ADMIT DATE FAC. ZIP Description/Valid Values Enter the beneficiary s last name, first name, date of birth (MMDDCCYY), full mailing address, ZIP code, and gender Enter the start date of the hospice benefit period in which the discharge or revocation is effective in MMDDYY format. Do not enter the initial hospice admission date. Enter the facility ZIP code of the provider 43 NOTR Claim Page Three Field RI Description/Valid Values Enter the release of information indicator. Valid values are: Y to indicate you have a signed statement on file R to indicate the release is limited or restricted N to indicate there is no release is on file 44 Change Request 9114 Issued: April 3, 2015 Effective date: May 4, 2015 Timely Filed NOE The election statement must include the patient s choice of attending physician. Changing the designated attending physician Filing a timely NOTR 45 15

16 Attending Physician Attending physician means: Nurse Practitioner (NP) who meets the training, education and experience requirements as described in Section (b) of 42 CFR 410 A physician identified by the individual, at the time he or she elects to receive hospice care, as having the most significant role in the determination and delivery of the individual s medical care (42 CFR Designation of the Attending Beneficiary Election Statement must include: Attending physician name National Provider Identifier (NPI) Language on the election form should include an acknowledgement by the patient (or representative) that the designated attending physician was the patient s (or representatives) choice. No special format for reporting attending 47 Changing the Designated Attending Physician File a signed statement with the hospice which includes: Identifying the new attending physician Date change is to be effective Can be no earlier than the date signed Date that the statement is signed and the patient s (or representatives) signature Acknowledgement that the change in the attending physician is the patient s (or representatives) choice 48 16

17 Medical Review Data 49 Medical Review Audits CY14Q4 5AH01-LOS>365 days Probes 5AP10- New Providers 5AP11-LOS.180 days & <365 days 5AP22- Medical Necessity CY15Q1 5AH01 50 Medical Review Data CY14Q4 CY15Q1 Claims Reviewed No response claims (56900) Claims Received Claims Denied CER 20% 23.4% 51 17

18 Medical Review Data Denial Code Description CY14Q4 CY15Q1 55H1L Terminal prognosis not supported # of claims % of denials # of claims % of denials % 38 46% Records not received 38 21% 12 14% 55H1F Physician certification or recertification was not received 21 11% 24 19% 55H1S FTF requirement not met 7 5% 17 21% 52 Terminal Prognosis Common causes for denials (55H1L) Beneficiaries condition stabilizes and no further decline Minimal to no weight loss No systemic infection No change in condition Poor documentation to support further decline No weights documented No documentation of oral intake Vague terminology such as patient is declining without further description of the decline. 53 Physician Certification Statement Common denials (55H1F) Lacks certification dates (from and through) Lacks a brief narrative Lacks verbal statement when the written is signed untimely Less frequent causes Missing oral/verbal statement Missing dates of physician signature 54 18

Face-to-Face Requirement Not Met Common causes for denials (55H1S) Face-to-Face note/attestation statement is missing or incomplete Face-to-Face is missing from the claim and/or the certification

19 Face-to-Face Requirement Not Met Common causes for denials (55H1S) Face-to-Face note/attestation statement is missing or incomplete Face-to-Face is missing from the claim and/or the certification Less frequent causes Face-to-Face was untimely Physician Signature did not appear under the certification 55 CERT A/B MAC Outreach & Education Task Force 56 CERT A/B MAC Outreach & Education Task Force A joint collaboration of the A/B MACs to communicate national issues of concern regarding improper payments to the Medicare Program Shared goal of reducing the national improper payment rate as measured by the CERT program Partnership to educate Medicare providers on widespread topics affecting most providers and complement ongoing efforts of CMS, the MLN and the MACs individual error-reduction activities within its jurisdictions Disclaimer The CERT A/B MAC Outreach & Education Task Force is independent from the CMS CERT team and CERT contractors, which are responsible for calculation of the Medicare fee-for-service improper payment rate

20 Participating Contractors Cahaba Government Benefit Administrators, LLC/J10 CGS Administrators, LLC/J15 First Coast Service Options, Inc./JN National Government Services, Inc./J6 and JK Noridian Healthcare Solutions, LLC/JE and JF Novitas Solutions, Inc./JH and JL Palmetto GBA/J11 Wisconsin Physicians Service Insurance Corporation/J5 and J8 58 CERT A/B MAC Outreach & Education Task Force The CERT Task Force educates on common billing errors and contributes educational Fast Facts to the CMS website CMS MLN Provider Compliance Fast Facts web page MLN/MLNProducts/ ProviderCompliance.html In addition, the CERT Task Force section on the NGSMedicare.com website provides a link to the CMS MLN Provider Compliance Fast Facts 59 CERT A/B MAC Outreach & Education Task Force CERT Task Force Web Page Go to our website, in the About Me drop down box, select your provider type and applicable state, click on Next, accept the Attestation. Choose the Medical Policy & Review tab, then choose CERT, the CERT Task Force link is located to the right of the web page. Task Force Scenarios Complying with medical record documentation requirements Documenting therapy and rehabilitation services Look for new articles added to this page and provided in your Updates 60 20

CERT A/B MAC Outreach & Education Task Force CMS works closely with the CERT A/B MAC Task Force and the CERT DME MAC Outreach & Education Task Force CMS has a web page dedicated to education

21 CERT A/B MAC Outreach & Education Task Force CMS works closely with the CERT A/B MAC Task Force and the CERT DME MAC Outreach & Education Task Force CMS has a web page dedicated to education developed by the CERT A/B MAC Outreach & Education Task Force Contracting/FFSProvCustSvcGen/CERT-Outreach-and-Education-Task- Force.html 61 RESOURCES 62 CMS Resources CMS Web site, Center CMS Transmittals CMS Internet-Only Manuals Publication , Medicare Benefit Policy Manual, Chapter 9 Publication , Medicare Claims Processing Manual, Chapter

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22 National Government Services Resources HHH portal Provider Resources > Acronym Search Education > Job Aids & Manuals Job Aids Claims & Appeals > Top Claim Errors Claims & Appeals > Claims: Medicare Secondary Payer Education > Webinars, Teleconferences & Events Upcoming education sessions Education > Past Events Presentation materials and event summaries 64 Updates Subscribe to receive the latest Medicare information. 65 Website Survey This is your chance to have your voice heard Say yes when you see this pop-up so National Government Services can make your job easier! 66 22

23 Medicare University Interactive online system available 24/7 Educational opportunities available Computer-based training courses Teleconferences, webinars, live seminars/face-to-face training Self-report attendance Website 67 Medicare University Self-Reporting Instructions Log on to the National Government Services Medicare University site at Topic =The Medicare Program: New Billing Requirements & Hot Topics from Your Medicare Medicare University Credits (MUCs) = 1 Catalog Number = TBA Course Code = TBA Visit our website for step-by-step instructions on self-reporting. Click on the Education tab, then the Get Credit link. This will open the Get Credit for Completed Courses web page. 68 Continuing Education Credits All National Government Services Part A and Part B Provider Outreach and Education attendees can now receive one CEU from AAPC for every hour of National Government Services education received. If you are accredited with a professional organization other than AAPC, and you plan to request continuing education credit, please contact your organization not National Government Services with your questions concerning CEUs

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Let s Chat: Hospice Notice of Election Timely Filing

Let s Chat: Hospice Notice of Election Timely Filing Let s Chat: Notice of Election Timely Filing January 2016 1700_0116 Today s Presenter Corrinne Ball, RN, CPC, CAC, CACO Provider Outreach and Education Consultant 2 Disclaimer National Government Services,