May 2007 Provider Bulletin Number 753. Hospice Providers. Changes to ICF/MR Room and Board Charges for Hospice Beneficiaries
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1 May 2007 Provider Bulletin Number 753 Hospice Providers Changes to ICF/MR Room and Board Charges for Hospice Beneficiaries This is an update to bulletin 743. A correction has been made regarding how to submit paper claims and Internet claims. The following information regarding billing using a National Provider Indicator (NPI) is the most current. On April 2, 2007, the Centers for Medicare & Medicaid Services announced an extension for the NPI implementation. The Kansas Medical Assistance Program (KMAP) contingency plan is that either the NPI or the KMAP provider ID will be accepted on claims until May 23, 2008, or until the Kansas Health Policy Authority (KHPA) determines and communicates an alternate date. Hospice providers are required to bill room and board charges for hospice beneficiaries residing in a nursing facility (NF), intermediate care facility for mental retardation (ICF/MR), or hospital swing bed. NFs include skilled nursing facilities, nursing facilities, and nursing facilities for mental health. ICF/MRs include privately owned and state institution ICF/MRs. These claims may be submitted on paper, electronically, or through the Internet. Because of the delayed NPI implementation, effective with processing dates on and after May 23, 2007, hospice providers can provide either the NPI or KMAP provider ID of the facility or hospital when billing for room and board services. KMAP requests that you submit the facility s NPI in the referring physician/provider field on the claim; however, the KMAP provider ID will be accepted until May 23, 2008, or earlier if directed by KHPA. At that time, providers will be required to submit the NPI, and claims submitted with the KMAP provider ID will deny. Paper Claims: Complete the claim as usual and document the NF, ICF/MR, or hospital swing bed NPI in field 17b or the KMAP provider ID in field 17a. Electronic Claims (such as 837P): Complete the claim as usual. Nursing facility, ICF/MR, or hospital swing bed providers must be included as the referring provider in loop 2310A or 2420A on hospice claims. Internet Claims: Complete the claim as usual and document the NF, ICF/MR, or hospital swing bed NPI in the referring physician field. Provider Electronic Solutions (PES): Complete the claim as usual and document the NF, ICF/MR, or hospital swing bed in the referring provider field under Header 2. EDS is the fiscal agent and administrator of the Kansas Medical Assistance Program for the Kansas Health Policy Authority. Page 1 of 6
2 Effective April 6, 2007, the Hospice Election Assignment window on the KMAP Web site was updated to reflect recent claims processing changes related to the use of these fields. New windows allow hospice providers to search for and select nursing facility information when entering the room and board hospice assignment via the KMAP Web site. In addition, help windows are available from the toolbar for each window used for hospice assignments. If you have questions or need help using the KMAP Web site, please contact the KMAP Customer Service Center at or For claims payment purposes, the nursing facility information must be available prior to May 23, This ensures all unpaid claims or adjustments for room and board services have the necessary information to process and pay accurately. Failing to include the nursing facility information will cause claims submitted to deny. Prior to May 23, 2007, the hospice provider will use the KMAP Web site to enter the nursing facility information for all beneficiaries that do not already have an end date on file for the hospice assignment. The hospice provider will not be able to use the KMAP Web site to update any records that were previously ended. The hospice provider must also provide the information listed below to the hospice coordinator for manual entry. The information should be provided for any beneficiaries that received room and board services beginning January 1, The nursing facility information will be used for claims processing that occurs on and after May 23, 2007, and ensures all unpaid claims or adjustments for room and board services have the necessary information to process and pay accurately. Failure to do this will cause claims submitted on and after May 23, 2007, to deny. Prior to May 23, 2007 the hospice provider must: Fax the following information to the hospice coordinator at Hospice provider name Hospice KMAP provider ID number Beneficiary first name Beneficiary last name Beneficiary date of birth Election start date Election end date Facility or hospital name Facility or hospital NPI (if not available, provide the full address) Information about the Kansas Medical Assistance Program as well as provider manuals and other publications are on the KMAP Web site at For the changes resulting from this provider bulletin, please view the Hospice Provider Manual, pages 7-2, 8-5, 8-9, and If you have any questions, please contact Customer Service at (in-state providers) or (785) between 7:30 a.m. and 5:30 p.m., Monday through Friday. EDS is the fiscal agent and administrator of the Kansas Medical Assistance Program for the Kansas Health Policy Authority. Page 2 of 6
3 7010. HOSPICE BILLING INFORMATION Updated 05/07 Providers should bill the rate for the service based on the KMAP Hospice Rates and instructions in Appendix II of the Hospice Provider Manual. Automated Processing of Nursing Facility and ICF/MR Room and Board Charges for Hospice Beneficiaries. Hospice providers are required to bill the room and board charges for hospice beneficiaries residing in NFs, ICF/MRs, or hospital swing beds. NFs include skilled nursing facilities, nursing facilities, and nursing facilities for mental health. ICF/MRs include privately owned and state institution ICF/MRs. Hospice providers are required to provide the National Provider Identifier (NPI) of the facility or hospital when billing for room and board services. The NPI is entered in the referring physician/provider field on the claim. Claims submitted without the NPI in the designated field will be denied. These claims may be submitted on paper, electronically, or through the Internet. Automated processing will allow these claims to process quickly and accurately by following the instructions below. Paper Claims: Complete the claim as usual and document the NF, ICF/MR, or hospital swing bed NPI in field 17b or the KMAP provider ID in field 17a. Electronic Claims (such as 837P): Complete the claim as usual. Nursing facility, ICF/MR, or hospital swing bed providers must be included as the referring provider in loop 2310A or 2420A on hospice claims. Internet Claims: Complete the claim as usual and document the NF, ICF/MR, or hospital swing bed NPI in the referring physician field. Provider Electronic Solutions (PES): Complete the claim as usual and document the NF, ICF/MR, or hospital swing bed in the referring provider field under Header 2. KMAP prefers the NPI is submitted for the referring physician/provider s identifier but the KMAP provider ID will be accepted until notified otherwise. BILLING INSTRUCTIONS 7-2
4 8400. Updated 05/07 As a reminder, there is a 10-day grace period starting at the time of admission or election to hospice care during which the provider must submit a hospice election via the KMAP Web site. The Web site guides the user through the process of electronic submission. If the entry date of the hospice election is beyond the 10-day requirement, the provider must fax the election statement and a written request to the hospice coordinator at The election statement must include the following information: KMAP provider name and number Facility or hospital name and address if billing for room and board charges Effective date of the election period Signature of the beneficiary or his/her legal representative Beneficiary Medicaid identification number Beneficiary date of birth The written request must include information regarding why the election was not entered using the KMAP Web site. This information is provided to the State Program Manager for consideration. An override to the 10-day requirement must meet strict guidelines set forth by the Kansas Health Policy Authority (KHPA). If the override request is approved, the election is backdated to the start date of care. If the request is not approved, it is not backdated and the new approval date will be nine days prior to the date the hospice coordinator received the hospice election statement. If KHPA does not grant approval of the override request, the approved date of the election period will be 10 days from the date the hospice coordinator received the hospice election, Claims will be processed using this approved date as the start of the hospice election. Advance Directives: Hospice providers participating in the Kansas Medical Assistance Program must comply with federal legislation (OBRA 1990, Sections 4206 and 4751) concerning advance directives. Specific Requirements 1. Each hospice must provide written information to every adult individual receiving medical care by or through the hospice. This information must contain: - the individual's right to make decisions concerning his or her own medical care. - the individual's right to accept or refuse medical or surgical treatment. - the individual's right to make advanced directives. - the Department of Social and Rehabilitation Services' "Description of the Law of Kansas Concerning Advance Directives." SRS does not provide copies of the description to providers. It is up to providers to reproduce the description. Providers are free to supplement this description as long as they do not misstate Kansas law. 2. Additionally, each hospice must provide written information to every adult individual about the hospice's policy on implementing these rights. 3. A hospice must document in every individual's medical record whether the individual has executed an advance directive. BENEFITS & LIMITATIONS 8-5
5 8400 Updated 05/07 The following services must be provided: Core Services A hospice must ensure that all the core services are provided by hospice employees. A hospice may use contracted staff, if necessary, to supplement hospice employees in order to meet the needs of patients during periods of peak patient loads or under extraordinary circumstances. If contracting is used, the hospice must maintain professional, financial and administrative responsibility for the services and must assure that the qualifications of staff and services provided meet all requirements. Counseling Services These services must be available to both the individual and the family. It shall include dietary, spiritual, and bereavement counseling. Dietary counseling must be provided by a registered dietician. Spiritual counseling shall include notice to the beneficiary as to the availability of clergy. Drugs All drugs related to the terminal illness of the patient are covered by the hospice program and are included in the daily rate. All drugs not related to the terminal illness or related conditions for beneficiaries receiving hospice care, require prior authorization (PA). A signed statement from the hospice provider will be needed for all drug prior authorization (PA) requests for beneficiaries assigned to that hospice provider. The statement must include rationale for non-coverage of the drug(s) by the hospice provider. The signed statement from the hospice provider can be mailed or faxed directly to the PA unit or sent to the pharmacy. Kansas Medical Assistance Program Fax : or Office of the Fiscal Agent P.O. Box 3571 Topeka, KS HCBS Services Beneficiaries of hospice services may also be eligible to receive services through the Home and Community Based Services (HCBS) Program. However, HCBS services may not duplicate services being rendered by the hospice provider. To ensure services are not being duplicated and the hospice beneficiary is receiving the quality of care that he or she is entitled to, KMAP may ask for written care plans from hospice and HCBS providers. Hospice is the coordinator of all care services that the hospice beneficiary is receiving. BENEFITS & LIMITATIONS 8-9
6 8400 Updated 05/07 Home Health Aide and Homemaker Services These services must be available and adequate in frequency to meet the needs of the beneficiary. A registered nurse (RN) must visit the home site at least every two weeks when aide services are being provided. This visit shall include a written assessment of the aide service. Written instructions for patient care are prepared by the RN. Duties include personal care, ambulation and exercise, household services essential to health care at home, assistance with medications that are ordinarily self-administered, reporting changes in the patient's condition and needs, and completing appropriate records. The hospice must be the sole provider of these services. Inpatient Care Hospice is to notify the KMAP Prior Authorization department of any hospital admission. Care must be available for pain control, symptom management and respite purposes. It may be provided in a participating hospice inpatient unit, hospital, or nursing facility the hospice has contracted with that meets the special hospice standards regarding staffing and patient areas. Services provided in an inpatient setting must conform to the written plan of care. General inpatient care may be required for procedures necessary for pain control or acute or chronic symptom management which cannot be provided in other settings. Medical Social Services These services must be provided by a licensed social worker, under the direction of a physician. Social work activities include assessing client needs, securing resources to meet those needs, working with family issues, problem-solving intervention and supportive one-toone work with beneficiaries. Nursing Services The hospice must provide nursing care and services by or under the supervision of an RN. Nursing services must be directed and staffed to assure that nursing needs of patients are met. Patient care must be specified in a plan of care and must be provided in accordance with licensing standards. Physical Therapy, Occupational Therapy and Speech Language Pathology These services shall be provided for the purposes of symptom control or to enable the beneficiary to maintain activities of daily living and basic functional skills. When provided, they must be offered by persons either appropriately certified or under the supervision of one appropriately certified in the respective discipline to offer that service. BENEFITS & LIMITATIONS 8-10
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