CMS Hospice-related Q&A s April 2011 This list is compiled from the CMS Hospice Center (http://www.cms.gov/center/hospice.asp) with questions and answers that were posted or updated in April, 2011. Each question is linked to the Q&A as posted on the CMS website. NHPCO will continue to gather Q&As as they are posted and provide the summary, by category, each month as a part of the NHPCO Regulatory Round-Up. I. QUESTIONS ABOUT HETs SYSTEM Published 04/15/2011 03:24 PM Updated 04/19/2011 12:01 PM Answer ID 10576 Will HETS 270/271 return the Hospice code for revocation reason, e.g., transfer, death, or revoked? CMS has discussed the possibility of returning the Hospice Revocation Code on future HETS 271 responses. In the meantime, if the Hospice care has been revoked (Hospice Revocation Code = 1, 2, or 3), then HETS 270/271 will return a Hospice termination date. If the final Hospice bill has not yet been received (Hospice Revocation Code = 0), then HETS 270/271 will not return a Hospice termination date. Refer to Section 7.13 of the HETS 270/271 Companion Guide for further explanation. Published 04/15/2011 03:21 PM Updated 04/19/2011 11:59 AM Answer ID 10575 Does CMS plan to modify the HETS 271 response to display either the benefit period number or the last three election periods regardless of date of activity similar to the Medicare legacy eligibility systems that use CWF? HETS 270/271 only returns 27 months worth of history because, prior to January 1, 2011, that was the timely claim filing timeframe. To handle any overlap that may occur with the 60-day hospice certification, HETS 270/271 will return the certification dates 60 days prior to the "from date" on the 270 request since this would represent the oldest relevant Hospice data required for the timely submission of a claim. Published 04/15/2011 03:19 PM Updated 04/19/2011 11:59 AM Answer ID 10574 Does HETS 270/271 plan to add the patient status and patient indicator to the Home Health Prospective Payment System (PPS) episode information (as returned by Medicare legacy eligibility systems like HIQA and HIQH)? Currently, if a beneficiary is in continuous Home Health or Hospice episodes with a provider, this is reported as a single benefit period. Because of Medicare's new face-to-face visit requirements, it is important for providers to know exactly which benefit period or episode the patient is in. Are there plans for HETS 270/271 to report these periods/episodes in the same manner as they are reported in HIQA and HIQH? Page 1
There are no current plans to update the way in which Home Health and Hospice periods are combined and returned in the HETS 271 response. There is, however, a future change request that will return up to the 10 most recent Home Health and Hospice certification and recertification dates which support the new face-to-face visit requirements. These dates will be reported in the same manner as they are in the legacy Medicare eligibility HUQA and HIQA systems. : Published 04/15/2011 03:17 PM Updated 04/19/2011 11:58 AM Answer ID 10573 Explain why HETS 270/271 does not display "all" previous Hospice benefits periods. All Hospice benefit periods that overlap the requested dates are returned by HETS 270/271 but are not organized in the same manner as the Medicare legacy eligibility systems that utilize CWF. In HETS 270/271, the Hospice benefit periods are logically combined into larger periods representing continuous hospice care under the same provider. Refer to section 7.13 of the HETS 270/271 Companion Guide for further explanation. : II. QUESTIONS ABOUT THE FACE TO FACE ENCOUNTER Published 11/19/2009 11:49 AM Updated 04/29/2011 02:42 PM Answer ID 9917 Does the physician's attestation on the narrative, which is part of the physician's certification and recertification of Medicare hospice patients, have to use the language from the regulation verbatim? We have not mandated that specific language be included in the physician's attestation. Any language under the physician's signature which attests that by signing, the physician confirms that he/she composed the narrative based on his/her review of the patient's medical record or, if applicable, his or her examination of the patient meets the attestation regulatory requirement at 42 CFR 418.22(3)(iii). III. QUESTIONS ABOUT CLAIMS AND RECORDING VISITS ON THE CLAIM FORM Published 11/03/2009 08:35 AM Updated 04/29/2011 02:42 PM Answer ID 9887 Change Request 6440 requires time reporting of most hospice visits on claims. How should hospice providers report the time for visits when the visit takes less than 15 minutes? All visits up to 15 minutes are reported as one 15-minute increment, regardless of the length of the visit. Visits longer than 15 minutes are rounded to the nearest 15 minute increment (up or down). For example, a 5 minute visit is counted as 1 15-minute Page 2
increment, a 20 minute visit is counted as 1 increment, and a 25 minute visit is counted as 2 increments. Published 11/19/2009 11:45 AM Updated 04/29/2011 02:41 PM Answer ID 9915 Change Request (CR) 6440 requires reporting of allowable social worker phone calls, and the length of the call. When a social worker makes phone calls related to the patient's care during the course of a visit with the patient or his/her family, should those calls be reported, or should they be counted as part of the visit? Phone calls made on behalf of a patient during the course of a visit with the patient or his family should not be reported on hospice claims. Only report phone calls that are not made during a reportable visit, and which meet the criteria given in CR 6440: "Only phone calls that are necessary to the palliation and management of the terminal illness and related conditions as described in the patient's plan of care (such as counseling or speaking with a patient's family or arranging for placement) should be reported. Report only social worker phone calls related to providing and / or coordinating care to the patient and family, and documented as such in the clinical records." Published 11/19/2009 11:46 AM Updated 04/29/2011 02:41 PM Answer ID 9916 Change Request (CR) 6440 requires reporting of the length of most hospice visits. Some providers have staff spend time documenting during the course of a visit. For example, those using electronic medical records may record patient data in the medical record as the patient is being assessed. Should this documentation time be backed out of the visit time reported when the documentation occurs during a visit? To clarify the instructions in CR 6440, documentation time (such as the updating of medical records) which occurs during, and as part of, an otherwise covered and billable visit to a patient can be included in the time reported for the visit. Documentation time which occurs outside the context of such a visit is not reportable. Published 02/13/2008 07:56 AM Updated 04/21/2011 04:00 PM Answer ID 8904 How are visits counted for continuous home care (CHC)? CHC visits are counted in the same manner as Routine Home Care visits. An example of counting CHC visits would be where a registered nurse provides 4 hours of care in the morning and returns later in the day to provide 4 more hours of care in the evening; 2 nursing visits would be counted. If 3 nurses (in 3 consecutive 8-hour shifts) and one aide provide 24 hrs of CHC in a 24 hour period, 3 nursing visits and 1 aide visit would be counted. (Revised) Page 3
Reference Published 02/13/2008 07:59 AM Updated 04/21/2011 04:00 PM Answer ID 8906 If a hospice only uses licensed nurses to provide care, how will the home health aide visits be counted? The information on the claims does not identify what type of service is being provided, but merely identifies the number of visits by care provider type. Therefore, the visits provided by a licensed nurse would be reported as nursing visits. In this situation, there would be no home health aide visits reported on the claim. Reference Published 02/13/2008 08:11 AM Updated 04/21/2011 04:00 PM Answer ID 8913 Are attending physician visits by a physician not employed by or under contract with a hospice included on the claims data? No. The physician visits on the hospice claims are for reasonable and necessary visits by the hospice medical director or a physician who is employed by or under contract with the hospice. This includes any services provided by the hospice medical director or physician who is serving as the patient s attending physician. Services provided by a physician not employed by or under contract with a hospice are submitted on Part B claims and as such do not fall under the requirements of change request (CR) 5567. (Revised) Reference: (Revised) Reference Published 02/13/2008 08:13 AM Updated 04/21/2011 04:00 PM Answer ID 8915 If a hospice patient is at a contracted nursing home receiving Routine Home Care or Continuous Home Care, are the nursing home staff s patient care visits to the patient also included? No the number of visits to be included on the claims form is the number of visits provided by the hospice staff. (Revised) Reference Published 02/13/2008 08:23 AM Updated 04/21/2011 04:00 PM Answer ID 8919 Will CMS provide sample claim forms reflecting the changes in transmittal 1494, change request (CR) 5567? CMS does not typically provide sample claim forms for billing instructions. Medicare Page 4
contractors have discretion to develop such samples as part of their provider education efforts. Regarding the specific instructions in Transmittal 1494, sample claim forms could be misleading. The instructions intentionally provide hospices with flexibility and discretion in reporting, in an effort to reduce provider burden. For instance, some hospice software vendors have asked whether weekly service reporting (revenue codes 55x, 56x and 57x) must be accompanied by weekly reporting of level of care days (revenue codes 651 656). This is not required, but it would be accepted by Medicare systems if a provider chose to do so for their own administrative reasons. Similarly, Transmittal 1494 requires weekly reporting of service disciplines for each place of service. The place of service for each level of care is reported by hospices using Healthcare Common Procedure Coding System (HCPCS) codes Q5001-Q5009. Vendors have wondered whether this means the place of service HCPCS codes are required on all service lines. They are not, because Medicare can associate the individual services to the place of service by their associated dates. But if a hospice chose to report the HCPCS codes, it would be allowed. There are additional examples where hospices have discretion to choose among reporting options. Options not in conflict with the instructions in the transmittal are allowed. Such flexibility may be of value to hospice agencies in tailoring their response to the instructions to their own administrative processes. Published 02/13/2008 08:24 AM Updated 04/21/2011 04:00 PM Answer ID 8920 Hospices are required by Medicare instructions to submit claims on a monthly basis. Reporting of services in transmittal 1494 is weekly (Sunday-Saturday). How are hospices to report weeks that are split across two months? Hospices continue to be required to bill monthly. For the weekly service reporting, partial weeks may be reported consistent with the month being billed. That is, if the first 3 days in a week fall in one month and the last four in the next month, report a line for that week on the claim for the month that is ending, showing the date of the earliest service that precedes the month end and the number of visits that preceded the month end. Report a line for the same week on the claim for the following month, showing the date of the earliest service that follows the start of the month and the number of visits in the balance of that week. Published 02/13/2008 08:26 AM Updated 04/21/2011 04:00 PM Answer ID 8922 Transmittal 1494 says that if a beneficiary s residence changes to cause the Core- Based Statistical Area (CBSA) reported on the claim to also change, the CBSA applicable at the end of the billing period should be reported. In the past, some hospices have submitted more than one claim in a month, showing the applicable CBSA code on each claim. Why can this no longer be done? As the previous question noted, hospices have been subject to Medicare s monthly billing requirement for repetitive services for several years. So it was not appropriate in the past to submit more than one claim in a monthly billing period. Using the CBSA code at the Page 5
end of the billing period has been CMS guidance for these cases for some time, following the precedent set on claims for home health episodes. This is just the first time this guidance has been placed in the Medicare Claims Processing Manual. Published 02/13/2008 08:28 AM Updated 04/21/2011 04:00 PM Answer ID 8924 What will a hospice do if it receives additional information about discipline visits or physician visits after the claim for a given month of services has already been submitted? If a hospice receives late information about reportable visits for any reportable discipline other than physicians, it will adjust the previously submitted claim to add the required information that was omitted. If a hospice receives late information about separately billable physician visits, it may either adjust the previously submitted claim or submit a separate late charge claim (type of bill 815 or 825) for the visits. (Revised) Published 02/13/2008 08:30 AM Updated 04/21/2011 04:00 PM Answer ID 8926 How should hospices report charges on the service discipline line items on the claim? Should they be included in the total charge field for the claim? Hospices are to report charges as accurately as possible. Charges are required to provide supplementary information and because many provider billing systems cannot generate service lines on a claim without a charge amount. Medicare systems will move the submitted charge amounts to be non-covered charges, indicating on remittances that these charges are bundled into the per diem payments made on the level of care line items. Charges for all lines are included in the total charge for the claim. (Revised) Published 02/13/2008 08:33 AM Updated 04/21/2011 04:00 PM Answer ID 8929 What will happen if required data are missing from lines reporting visits on hospice claims? If revenue code lines reporting visits (revenue codes 55x, 56x or 57x) are received without units or charges, the claim will be returned to the provider. Please note that this is also true for the reporting of site of service Healthcare Common Procedure Coding System (HCPCS) codes on hospice level of care revenue code lines (revenue codes 651, 652, 655 and 656). Claims submitted without the site of service HCPCS codes are currently returned to the provider. Page 6
Published 02/13/2008 07:53 AM Updated 04/21/2011 03:59 PM Answer ID 8902 What constitutes a reasonable and necessary social worker visit? As noted in responses above, a reasonable and necessary patient care visit by a social worker is a visit that is reasonable and necessary for the palliation and management of the terminal illness and related conditions as described in the patient s plan of care. Due to the nature of a social worker s functions, counseling or speaking with a patient s family or arranging for placement, would constitute a visit. (Revised) Published 02/13/2008 07:58 AM Updated 04/21/2011 03:59 PM Answer ID 8905 For hospice services, why are rounds not considered a patient care visit? Rounds are an administrative activity rather than a patient care activity. A visit provided during rounds would not be considered a patient care visit unless a patient required a physician s assessment and/or intervention during the visit. Rounds performed in a facility for the purposes of writing orders or any other non-patient care required services, do not count as visits. (Revised) Published 02/13/2008 08:02 AM Updated 04/21/2011 03:59 PM Answer ID 8909 For hospice claims, what is the reporting week? As noted in CR 5567, the reporting week begins on Sunday and ends on Saturday. The workweek is defined so as to ensure consistent reporting parameters. Published 02/13/2008 08:04 AM Updated 04/21/2011 03:59 PM Answer ID 8911 Do supervision, education and orientation of staff constitute a visit for hospice services? No. These do not constitute a patient care visit. (Revised) Published 02/13/2008 08:12 AM Updated 04/21/2011 03:59 PM Answer ID 8914 Do travel time and time in IDG meetings count as a visit for hospice services? Page 7
No, as these are not patient care activities, they do not count as a visit. (Revised) Published 02/13/2008 08:14 AM Updated 04/21/2011 03:59 PM Answer ID 8916 How accurate should the charges on the claims be for hospice services? The charges on the claims are to be as accurate as possible. At this time, the charges will be used for research purposes only. (Revised) Published 02/13/2008 08:22 AM Updated 04/21/2011 03:59 PM Answer ID 8918 How will the changes in Transmittal 1494, change request (CR) 5567, be handled in various claim formats (e.g. electronic 837I claims, PC ACE-PRO 32 submissions, Direct Data Entry, hard copy claims)? The billing instructions in Transmittal 1494 do not vary across claim formats. The revisions to the Medicare Claims Processing Manual, chapter 11, section 30.3 describe the data elements required to be submitted on the newly required lines that report nursing, home health aide (also known as hospice aide) and medical social worker visits to hospice patients. These data elements should be reported in accordance with the standards and general instructions that govern each claim format. Published 02/13/2008 08:25 AM Updated 04/21/2011 03:59 PM Answer ID 8921 How should hospices report weeks in which an admission or a discharge occurred and as a result services are not provided for an entire Sunday-Saturday week? Hospices should report admission or discharge weeks identically to other weeks on the claim, showing the number of visits provided during the Sunday-Saturday period. The number of visits in these partial weeks would likely be reduced due to the fact that fewer than 7 days were available to provide services, but the reporting requirements are the same as for full weeks of service. Published 02/13/2008 08:27 AM Updated 04/21/2011 03:59 PM Answer ID 8923 Hospice services have always been paid on a per diem basis? Does the weekly reporting of services change this? Page 8
No. Hospices continue to submit claim lines for each level of care they provide at each site of service. The units reported on these lines continue to represent days and Medicare s payment continues on a per diem basis. The additional lines on hospice claims reporting visits per week do not currently affect payment, but are for data collection purposes only. The charge information is for research purposes only.(revised) Published 02/13/2008 08:31 AM Updated 04/21/2011 03:59 PM Answer ID 8927 For hospice claims, in what order should the various lines on a monthly claim be sorted- by date or in revenue code order? Hospices have discretion regarding the sort order of the line items on their claims. Medicare systems will accept any sort order and re-sort the ideas as needed during processing. Published 02/13/2008 08:32 AM Updated 04/21/2011 03:59 PM Answer ID 8928 For hospice services, why did the reporting of visits also bring a new requirement for the admission date on claims to match the effective date of the hospice election? This requirement is not new. The instruction reading Enter the admission date, which must be the same date as the effective date of the hospice election or change of election was carried forward into the current Medicare Claims Processing Manual (Pub. 100-04) from the paper-based Hospice Manual (Pub. 21). It has been in place for more than a decade. (Revised) Published 05/07/2008 07:56 AM Updated 04/21/2011 03:59 PM Answer ID 9117 How should a hospice provider count visits when Respite Care is provided in a contract facility? At this time, when a hospice patient is receiving Respite Care in a contract inpatient facility, the hospice should only count the visits made by its employees. Respite care is given for up to 5 consecutive days when the patient s caregiver needs a break. IV. OTHER HOSPICE RELATED QUESTIONS Published 04/27/2011 09:37 AM Updated 04/29/2011 11:26 AM Answer ID Page 9
10602 How do you define continuum of care? Does this include acute hospitals, nursing homes, home health, community-based organizations? Are you expecting CBOs to coordinate across "all" settings? The nursing home discharge is a completely different set of client needs than a discharge home; could we focus on one discharge location? Yes, hospitals, nursing homes, home health, SNF, and hospice are all part of the continuum of care, and we expect CBOs to coordinate across all settings. Beneficiaries often experience multiple transitions following discharge from the hospital and therefore a CBO must follow that beneficiary across various settings if there is any hope of reducing avoidable admissions. Page 10