Palmetto GBA Hospice Coalition Questions November 6, 2001 Billing 1) A hospice patient needs to have an outpatient procedure that is not directly related to the patient's terminal diagnosis. The hospital refuses to bill Medicare because of past denials. What steps would you suggest that we take? When a patient receives services not related to their terminal diagnosis, the patient s regular Medicare benefits should cover those services, this is assuming that the other criteria is met, services are ordered and reasonable and necessary, etc. The provider of the services should list an 07 condition code on their claim to indicate the services provided are not related to the terminal illness. The hospital should contact their Part A Intermediary for assistance in the processing of their claim. 2) A Medicare beneficiary in the skilled nursing facility is allowed to elect the Medicare hospice benefit, provided that the skilled care is for a medical problem unrelated to the terminal illness. a) I believe that CMS has released a statement to that effect. Could we have a copy of it? b) What additional documentation would you suggest that each provider submit to avoid the claim being denied on the first submission? a) We do not have a copy of the statement that the question refers to. However, notes from a conference call with CMS on October 5, 1999 indicate: Our expectation [CMS] is that hospice services provided to a hospice patient residing in a nursing home look no different than hospice services provided to a hospice patient residing in a private residence. Hospice is responsible for all care related to terminal illness/related conditions. The NH is responsible for room and board. (Medicare does not pay for room and board). The hospice maintains professional management responsibility for all services related to the terminal illness/related conditions and is required to provide all core services (including nursing services). The hospice can arrange for another entity/provider (including the nursing home) to provide the non-core services. 1
The hospice and the NH must have a written agreement. Medicare can make a hospice payment and a SNF payment if the reason for the hospice election and the reason for the SNF stay are unrelated. A SNF stay can be confusing with a hospice patient in a SNF. b) The hospice agency should submit the specific documentation requested in the ADR. Any other supporting documentation that shows evidence that the reason for hospice care is unrelated to the SNF stay and that the SNF is the beneficiary s place of residence should be included. The best way to ensure payment for the claim is to sufficiently document the patient s condition, terminal illness, reason for hospice care, etc in the clinical record and nurse s notes, so as to paint the most thorough picture of the patient for the nurse reviewers to base their determinations on. The SNF should include the 07 condition code on their claims to indicate the services provided are not related to the terminal illness. The SNF should contact their Part A Intermediary for assistance in the processing of their claim. We contacted the Claims Department at Palmetto GBA for additional information concerning the use of the 07 condition code on the SNF claim. If the SNF bills the original claim without the 07 condition code included, when the notice of election is submitted, the SNF claim will process, but an alert will be sent to the Claims Department to take back the SNF payment. If the SNF claim is submitted with the 07 condition code, then everything will process and no alert will be sent. 3) Occasionally our medical director makes home visits to patients for whom he is not the attending physician. May we bill for those visits? Is so, what procedure should we follow? Any service rendered by a physician other than the attending physician is classified as a consulting physician service. Medically necessary visits to provide professional physician services by a medical director would fit this category. Please note that professional physician services as designated by the appropriate CPT-4 code are the only physician services which are separately billable to Medicare Part A. The visits should be billed using the HCFA 1450 (UB-92). On the UB-92 use revenue code 0657 with the appropriate CPT-4 code that was valid during the time the service was provided. The unit field should report the total number of times each type of service was provided during the billing period, i.e., each visit represents one unit. These services will then be paid to the hospice at 100% of the fee schedule for the area in which the hospice is located. This physician payment is included in the hospice aggregate cap amount. 4) When a patient transfers from one hospice to another, can both programs bill for the day of transfer? 2
The reference to this question can be found in the HCFA Publication 21 Hospice Manual, Transmittal 56; dated November 1999, Clarification of Reimbursement for Transfers that result in same day Hospice Discharge and Admission. This section clarifies that both the discharging and admitting hospice can bill for the same patient on the same day. You may also reference the Palmetto GBA Hospice training manual, section 4, page 82. This section states that hospices should communicate with each other to decide exactly how the coordination of the beneficiary's HMB will be handled. Hospice 1 should send the patient's history and POC to hospice 2 along with the change statement. Hospice 1 should then discharge the patient with a 811/821 or a 814/824 bill type and a status code of 01. The first hospice should not include an occurrence code of 42. The 42 would terminate the patient from the HMB. The new hospice must send the Notification of Change (81C/82C) to the Intermediary. The date of admission on the Notification of Change should be the date the patient was admitted to hospice 2. The second hospice agency should maintain the current benefit period by obtaining a physician certification (short certification) to continue the current benefit period. Palmetto GBA will request clarification from CMS concerning obtaining a short physician certification from the second hospice agency. Clarification: The following clarification was received on 2/4/02: We (CMS) do not have anything in the statute or regulations to require a short certification. The certification from agency one should transfer with the patient to agency two. Instead of requiring a short certification, it is recommended that the first agency provide the second agency with the documentation that supported the original diagnosis and prognosis, along with the copy of the actual certification. Cost Report 5) Following the desk audit of our cost report, we received a letter via fax after 3:00 p.m. on Friday stating that we needed to review Palmetto GBA s findings and respond within 10 days, or the findings would stand. Because the executive director was scheduled to be off the next week and the 10 days ran out on the following Sunday, the task to follow-up on her questions about the findings were delegated to the compliance coordinator. She called the person identified as the contact in the faxed letter. The following should be noted: a) The contact person was astonished to receive our call, as she did not know she had been listed and stated she did not have the expertise to help. 3
b) We spoke with different people and no one could tell us why an adjustment in patients served and days of care had been made. c) There was no trail that we could find indicating who made the adjustment or why it was made. At every step of the way, we were told not to worry about it because no money was connected with the adjustment. d) We explained that apparently we have made an error and we need to ensure that we have not perpetuated the error in the fiscal year that has just closed. e) Everyone was pleasant and friendly but no one had answers. We still do not know what the problem was. f) The blue cover final report was received last week with a Program Integrity Review letter indicating what will happen if an adjustment occurs that though not meeting the HCFA criteria of abuse on their initial identification, could, if repeated in subsequent cost filings (after identification and notification to the provider), be considered as program abuse and at that time would be reported to the HCFA Regional Office. How can this type of letter be justified if Palmetto GBA cannot identify or explain the error that led to the adjustment? Where do we go from here? Without a provider name or number, I cannot comment specifically on the situation identified in this question. However, I can address the two main issues in this question: the adjustment to patient census and Medicare days and the issue of the Program Integrity Review form. 1) As is noted in the adjustment report that goes out to the provider, we adjust the Medicare days and patient census to agree to what is reported in the PS&R. If the provider does not agree with the PS&R summary report, they would need to contact their reimbursement consultant to request a detail report. They can then compare this report to their own data to identify the discrepancies. If the provider can show that there was an error in the PS&R, they can submit the documentation to the audit department and request a reopening of their Medicare cost report. 2) Audit is required to conduct a Medicare Integrity Review of all finalized cost reports. The purpose for the review is to identify adjustments that could be considered by CMS to be an abuse to the Program. Most cost adjustments would not be considered abusive on their initial identification; however, if these adjustments are repeated year after year, they could be considered a program abuse at a later date. The purpose of the Program Integrity Review form is to notify the provider of these specific adjustments. Any adjustments of this nature are listed specifically on the form and if there are no adjustments of this nature, the word "NONE" usually appears. It should be noted that all cost report settlements receive this form. It should also be noted that Palmetto does not consider settlement data adjustments (or adjustments to agree the provider's Medicare census and statistics to the PS&R) to be program integrity issues. These adjustments would not be listed on this form. I have reviewed all hospice 4
settlements performed thus far to verify that settlement data adjustments were not reported on this form. I found no exceptions. Additional information was shared during the 1:00 P.M. conference call with the Gulf Coast Office. Please refer to the Additional Information Section. 6) We believe the patient count variance cited in the cost report question above could be related to MSP patients, although the days of care adjustment does not agree. How does Palmetto GBA count MSP patients and the days of care provided to them? Are they private insurance or Hospice Medicare? The audit department simply adjusts the patient census reported on the provider's cost report to what is on the PS&R. It is recommended that the provider request a detail PS&R from the reimbursement department to identify exactly what makes up the patient census number. Additional information was shared during the 1:00 P.M. conference call with the Gulf Coast Office. Please refer to the Additional Information Section. LMRPs 7) We received a denied rebuttal for a patient with dementia from the Benefit Integrity Unit. The denial was based on the fact that the patient had no documented change in condition or functional abilities since her admission to hospice, which indicates that there was not a rapid decline in the patient s condition. This patient met the 7C Functional Assessment Staging Scale with the exception that she, on occasion, could ambulate independently with the use of a walker, but she was at high risk for falls. Due to her dementia it was difficult to keep her from ambulating independently. In fact, during the denied period she fell and injured her back and required pain management. The patient experienced a 6% weight loss in the two months prior and an additional 8% weight loss in the two months following the review period. The denial stated the criteria requires evidence of a 10% weight loss during the previous six months. This patient also had congestive heart failure with an exacerbation episode just prior to her admission. During this episode she was hospitalized with chest pain, bradycardia and an oxygen saturation level of 82%. The chest pain was unrelieved with medication so it was treated with a lidocaine drip. Following hospice admission her CHF symptoms were fairly well controlled due to close monitoring by the hospice staff. a) The LMRP for dementia does not require a change in condition or functional abilities. Is this now a requirement? 5
b) Even though the patient had a clearly downward weight trajectory, the period was denied because the full 10% did not occur in the previous six months. Please explain this rationale. The purpose of the coalition meeting is not to discuss specific beneficiary cases. In order for Palmetto GBA to provide assistance concerning specific beneficiary cases, we would suggest that the provider write a letter to the Benefit Integrity Unit and the Reconsideration and Appeals department with a copy of the letter also being sent to Dr. Feliciano. The request would need to identify the beneficiary, HICN and the dates of service. Each area would then be able to review the details of the actual documentation and then respond accordingly. During the Hospice Coalition meeting the beneficiary specific information was given to the Manager of the Reconsideration/Appeals Department. 8) We recently were denied payment for services provided to a patient with end stage Parkinson s disease. The reconsideration determination upheld the decision for the denial. The documentation indicated that his condition was extremely compromised and deteriorating. The letter from Palmetto denying the reconsideration stated that the documentation did not show the patient experienced a decline in condition or support a prognosis of six months or less according to the local medical review policy criteria for dementia or heart disease. The letter goes on to list all the requirements for the LMRPs for dementia and heart disease elaborating on why the patient did not meet the criteria for those two diagnoses. The patient did not have dementia and there was no documentation in our appeal packet that this diagnosis was ever present. Although the patient had severe coronary artery disease along with hypertension, arrhythmia and an unresectable abdominal aortic aneurysm, heart disease was not his terminal diagnosis; however, it was a very significant comorbid condition along with dysphagia resulting from a previous transischemic accident. This patient s terminal diagnosis was Parkinson s disease. Why is care being denied based on LMRPs for diagnoses when neither is the beneficiary s terminal diagnosis? The purpose of the coalition meeting is not to discuss specific beneficiary cases. In order for Palmetto GBA to provide assistance concerning specific beneficiary cases, we would suggest that the provider write a letter to the Benefit Integrity Unit and the Reconsideration and Appeals department with a copy of the letter also being sent to Dr. Feliciano. The request would need to identify the beneficiary, HICN and the dates of service. Each area would then be able to review the details of the actual documentation and then respond accordingly. During the Hospice Coalition meeting the beneficiary specific information was given to the Manager of the Reconsideration/Appeals Department. General 6
9) A patient is admitted to a hospital for a non-related diagnosis (hip fracture). At some point during the stay, the patient's terminal diagnosis becomes the primary reason the patient continues to be hospitalized (heart disease in the ICU). Please explain how to handle this situation from a billing, care plan and visit frequency perspective. At the point that it becomes necessary for the patient to be hospitalized for care related to the terminal illness the standard general inpatient care guidelines become applicable. The necessary changes to the care plan should be made, and services should be provided in a contracted facility. The hospice remains the professional manager of the patient s care, despite the physical setting. The hospice begins to bill for general inpatient upon meeting the above guidelines. At this time the hospital would no longer be billing Medicare, rather they would be billing the hospice based upon the contract in place. The visit frequency would be based on the needs of the patient with the care that is being provided by the hospital staff taken into account. 10) Can Palmetto PBA report the average number of days billed per episode of general inpatient, respite and continuous care levels of care? Please refer to Attachment A. 11) The COPs state that the election statement must include the effective date of the election. Nothing in the language states or implies that the beneficiary has to be the one writing the election date on the statement. Recently, however, medical review indicated that the patient must be the one completing this date. Please clarify medical review's perspective with the law. If the hospice representative completes the form, including the election date and the patient then signs it, is this acceptable? As stated in the Code of Federal Regulations, 42CFR, Section 418.24-Election of Hospice Care, when the beneficiary elects hospice, they or their legally identified representative must sign the election form to indicate that they are electing hospice and understand what the election of the benefit means. The Medical Review representative suggested that the beneficiary should date the form to ensure that the beneficiary is aware of what they are signing. 12) Under what circumstances can an advanced practice nurse or PA be paid for the care of a hospice patient? Nurse Practitioners services are only billable if they are providing services on behalf of the non-employed attending physician. Those services are billed to the Medicare Part B Carrier and would have to adhere to the Medicare Part B billing guidelines. They couldn t bill unless it was under the incident to provision and billed under the attending doctor s provider number. If the non-employed 7
attending physician has to be out of the office, then he/she needs to get a locum physician to substitute or have a reciprocal arrangement, as only services related to the terminal condition provided under the non-employee attending physician s UPIN will be paid. Palmetto GBA is requesting additional information from the South Carolina Part B Carrier and from CMS. 13) If the service is for a diagnosis unrelated to the terminal diagnosis, under what circumstances can the above provider bill? According to the Centers for Medicare & Medicaid Services (CMS) Publication 21, Section 303.2, Billing for Covered Medicare Services Unrelated to Hospice Care, Any covered Medicare services not related to the treatment of the terminal condition for which hospice care was elected, and are furnished during a hospice election period, are billed to the intermediary or carrier for nonhospice Medicare payment. Additional Information: Palmetto GBA has received the following clarification from CMS concerning two questions from the August 7, 2001 meeting. 1. How should billing be handled when the initial certification is provided outside of the 2 weeks before and 2 days after time frame? For example, the verbal certification was not obtained and the written was obtained 5 days after admission. For clarification, the certification timelines are that for the first 90-day benefit period of hospice coverage, the hospice agency must obtain, no later than two calendar days after hospice care is initiated (by the end of the third day), the certification of terminal illness from the medical director of the hospice or the physician member of the hospice interdisciplinary group and the individual s attending physician (if the attending physician is not the medical director). The certification may be completed up to two weeks (14 days) before the hospice care is elected (effective date on the election statement). If a written certification is not obtained within two calendar days following the initiation of hospice care, then a verbal certification may be obtained within the two days following the initiation of hospice care, with the written certification obtained prior to billing for hospice services. According to Section 201 of the CMS Publication 21, if these requirements are not met, then no payment is made for the days prior to date that the certification is received. Therefore, in the example given above, if a verbal certification was not obtained and the written certification was obtained 5 8
days after the initiation of hospice care, then the hospice will not be able to bill for days 1 4 of the benefit period. The hospice would submit an 8X1 or 8X2 bill type and bill for only the covered days. (Do not submit the non-covered days as non-covered charges) Once the claim is received, the claims processing system will return the claim to provider (RTP) with a 38146 reason code for having a gap in service. Upon receiving the RTP, the provider should call the Provider Service Center and report the issue. The service center will write up the claim information and request that the claims department manually process the claim. Palmetto GBA will forward the question to CMS for additional clarification. Clarification: There is no additional clarification. Publication 21, Section 201, specifically states that if the timely certification requirements are not met, then no payment is made for the days prior to the (signed) certification. Instead, payment begins with the day of certification. 15. A nursing facility owns a hospice and will only allow its residents to receive services from that hospice. Please comment on this practice. Medicare beneficiaries should have access to all providers regardless of relationships to other facilities. As a part of the Medicare provider agreement, providers should not deny access to services for Medicare eligible beneficiaries. Additionally, the BBA 1997 indicated that upon discharging from a hospital the patient should receive information concerning all providers in their service area. Palmetto GBA will forward the question to CMS for additional clarification. Clarification: These requirements of the BBA of 1997 pertain to hospitals. Nursing Facilities (NFs) may contract with the hospice of their choice. The patient then, must decide if they wish to receive hospice services from that NF or whether or not they will go with another NF. Ultimately, the patient has the right to choose a provider of services (Section 1802), providing the provider can accept him/her. As long as the patient is satisfied with their choice of the NF and hospice, even thought it may be the only hospice the NF contracts with, then we accept it. If you as the FI suspect fraud and/or abuse you may report it to the local Office of Inspector General (OIG). If you suspect that the NF is not providing the appropriate level of services or lacks the appropriate quality of care, you may report it to the local Sate Survey and Certification Agency. 9
2. Hospice Reversal Rates, Attachment B. 3. Population-level information relating to the Non-Cancer Length of Stay (NCLOS) Rates. The information is stratified by region/policy and includes the NCLOS Rate frequency and distribution for each region/policy as well as the frequency and distribution of the General, Provider-Specific NCLOS Rates. Attachment C. Explanation of Attachment C-NCLOS Rate Analysis, Palmetto GBA Provider Population, January 1, 2001-June 30, 2001 1. Second and third slides provide an overview of the NCLOS Rates. 2. The next ten slides provide information on Policy-specific, Population NCLOS Rates for Palmetto GBA s four regions. Gulf Coast (FL, GA, AL, MS), Midwest (IL, IN, OH) Southeast (SC, NC, TN, KY), Southwest (TX, OK, AR, NM, LA) and then the four regions combined. 3. The next 45 slides show the frequency and distribution of Policy-specific, Provider specific NCLOS Rates for each of the four regions and then for the four regions combined. 4. The final slide shows the frequency and distribution of General, Providerspecific NCLOS Rates (i.e., all non-cancer claims subject to the non-cancer LMRPs, for a single provider) for the four regions combined. 1:00 Conference call concerning focused review of Cost Report A conference call was held with the Manager Lynda Hebbeln of the Gulf Coast Audit and Reimbursement Department concerning questions surrounding the Hospice Cost Report and specifically questions concerning a agency which was selected for a focused review of their cost report. Ms. Hebbeln indicated that she may be contacted concerning questions about focused review of cost reports. She may be reached at (727) 773-9225, extension 15616. The on-site audits are considered the first efforts in obtaining information concerning the hospice cost reports. It is an educational process for both sides (Palmetto GBA and the hospice provider). If a provider is selected for a focused review of the cost report they will receive a letter of notification. The reviews will be completed during the time period of October 2001 July 2002. Comments were received concerning the letter of notification. The hospice community has indicated that the letter is confusing. A letter should have specifically been developed for the hospice community. The letter used was 10
geared more towards home health agencies, and a letter should be developed to include more language geared towards hospice. The following requests were made concerning additional information about the focused reviews: 1) A What s New article was requested concerning what action or documentation the hospice provider should be expected to obtain for the review. Ms. Hebbeln indicated that her staff would be able to provide some additional information concerning the focused review process. 2) Develop a Provider Tips list concerning on - site review; for example, depreciation tax purposes versus Medicare purposes longest life, information concerning salvage value assigned and information concerning the Section of the HIM 2150, about Home Office Providers. 3) Develop Most Common Errors from the settlement of the focused review of the cost reports. 11
ATTACHMENT A The following table contains mean and median values for selected revenue codes by provider state. The unit for revenue code 652 is hours and the unit for the other revenue codes is days. For the purposes of the current analysis, an episode was defined as the period from the admit date through the last billed to date for a beneficiary. Please note that by using this definition, it is possible for a beneficiary to be represented more than once in the data. Hospice claims with an admit date of January 1, 2001 or later processed on or before September 30, 2001 were included in the analysis. The mean and median is calculated using only episodes that have a least one claim line with that revenue code. Mean & Median for Selected Revenue Codes by Provider State State (State Code) & Total Episodes Alabama (01) N = 7,237 Arkansas (04) N = 2,974 Florida (10) N = 37,477 Georgia (11) N = 9,516 Illinois (14) N = 14,248 Indiana (15) N = 6,286 Kentucky (18) N = 4,999 Louisiana (19) N = 4,332 Mississippi (25) N = 4,041 New Mexico (32) N = 2,077 North Carolina (34) N = 8,452 Ohio (36) N = 17,204 Oklahoma (37) N = 6,326 South Carolina (42) N = 3,792 Revenue Code Episodes Having Revenue Code Mean Median 0652 292 50.4 hrs 32.0 hrs 0655 93 4.5 days 5.0 days 0656 547 7.4 days 5.0 days 0652 39 27.7 16.0 0655 81 4.4 4.0 0656 313 10.6 5.0 0652 5,489 108.7 58.0 0655 392 4.3 5.0 0656 12,251 6.4 4.0 0652 83 39.1 26.0 0655 164 4.5 5.0 0656 1,939 7.2 5.0 0652 535 75.8 48.0 0655 132 4.1 4.0 0656 2,813 5.0 4.0 0652 56 12.8 9.0 0655 69 4.0 4.0 0656 1,028 7.0 4.5 0652 111 42.7 27.0 0655 80 4.2 4.5 0656 1,097 5.9 4.0 0652 85 51.5 36.0 0655 70 4.1 4.0 0656 520 8.6 5.0 0652 124 111.5 39.0 0655 49 4.0 5.0 0656 345 18.1 9.0 0652 11 28.2 16.0 0655 76 4.7 5.0 0656 298 6.1 4.0 0652 107 35.6 24.0 0655 197 4.8 5.0 0656 1,788 7.7 5.0 0652 653 56.1 26.0 0655 600 4.5 5.0 0656 4,160 6.0 4.0 0652 219 23.7 15.0 0655 31 4.1 4.0 0656 301 5.7 4.0 0652 14 43.4 28.0 0655 70 4.4 5.0 0656 353 8.0 5.0 12
Tennessee (44) N = 4,995 Texas (45/67) N = 24,261 0652 111 55.0 21.0 0655 64 5.0 5.0 0656 890 8.5 5.0 0652 2,330 79.9 50.0 0655 341 4.4 5.0 0656 4933 5.7 4.0 13
ATTACHMENT B 14
ATTACHMENT C NCLOS Rate Analysis Power Point Presentation 15