CMS CR 6440: Additional Documentation on Hospice Claims Related Q&A s ID# 8901 - Published 02/13/2008 Updated 04/09/2010 What constitutes a patient care visit that is reasonable and necessary? A reasonable and necessary patient care visit means a visit to provide care 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. Hospices should count the number of visits, not the number of services performed during a single visit. For example, if a nurse visits to auscultate a patient's chest but auscultation is not necessary or warranted, it would not constitute a patient care visit. When counting visits to a patient in a facility, hospices should consider whether the visit would have been reported, and how it would have been reported, if the patient were receiving RHC in his or her private home. If a group of tasks would normally be performed in a single visit to a patient living in his or her private home, then the hospice should count the tasks as a single visit for the patient residing in a facility. Hospices should not record a visit every time a staff member enters the patient's room. Hospices should not record visits which are part of room and board services provided to a RHC patient residing in a facility. Room and board services may include, but are not limited to, delivery of meals, changing bed linens, housekeeping tasks, etc. (Revised) Link to Q&A: http://questions.cms.hhs.gov/app/answers/detail/a_id/8901/kw/8901 ID# 8902 - Published 02/13/2008 Updated 11/05/2009 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) Link to Q&A: http://questions.cms.hhs.gov/app/answers/detail/a_id/8902 ID# 8903 - Published 02/13/2008 Updated 04/09/2010 If multiple health care providers are providing care at the same time, does each count as a visit? Yes, as long as the visits are required for the palliation and management of the terminal illness and related conditions as described in the patient's plan of care and are not listed for the purposes of increasing the number of visits. For example, a nurse teaching another nurse to perform a procedure would not comprise 2 visits. A nurse and an aide turning a difficult patient would constitute one visit each (though there would likely be other tasks performed as part of those visits). (Revised) Link to Q&A: http://questions.cms.hhs.gov/app/answers/detail/a_id/8903 1
ID# 8900 - Published 02/13/2008 Updated 04/09/2010 How should hospice providers count patient care visits in a facility that is staffed 24 hours a day? As Hospices are not required to count visits by non-hospice staff to hospice patients receiving general Inpatient Care or respite care in contract facilities. However, for hospice patients receiving General Inpatient Care or respite care in hospice facilities, all visits related to the palliation and management of the terminal illness must be counted. Hospices are required to count all visits by their nurses, social workers, home health aides (also known as hospice aides), and physicians providing care regardless of the location of the patient or the level of care provided, if the visit is necessary for the palliation and management of the terminal illness and related conditions as described in the patient's plan of care. Additionally, with the implementation of CR 6440 on January 1, 2010, hospices must also report visits by physical therapists, occupational therapists, speech language pathologists, and some social worker phone calls. Please see Q&A #8915, which addresses counting of visits when Routine Home Care or Continuous Home Care is provided in a facility. The program transmittal indicated the need to count the number of patient care visits provided to Medicare beneficiaries. Hospice providers should create a mechanism that allows for counting how many times a hospice nurse, home health aide (also known as a hospice aide), social worker, physical or occupational therapist, speech language pathologist, or physician visits a patient, or the number of times a social work makes certain types of phone calls, for the purpose of providing care necessary for the palliation and management of the terminal illness and related conditions as described in the patient's plan of care. Regarding recording of visits when a Medicare hospice patient is residing in a facility and receiving routine home care (RHC) or continuous home care (CHC), the following guidance applies to any hospice patient living in a facility, as the facility is the patient's home. Visits which are part of room and board services and which are provided to a RHC or CHC patient residing in a facility should NOT be reported on hospice claims to Medicare (regardless of whether those services are being provided by hospice staff or facility staff not employed by the hospice). Room and board services may include, but are not limited to, delivery of meals, changing bed linens, housekeeping tasks, etc. Hospices should only report visits which are reasonable and necessary for the palliation and management of the terminal illness and related conditions. When making the determination as to whether or not a particular visit should be reported, a hospice should consider whether the visit would have been reported, and how it would have been reported, if the patient were receiving RHC in his or her private home. If a group of tasks would normally be performed in a single visit to a patient living in his or her private home, then the hospice should count the tasks as a single visit for the patient residing in a facility. Hospices should not record a visit every time a staff member enters the patient's room. Hospices should use clinical judgment in counting visits and summing time. (Revised) References: http://www.cms.hhs.gov/transmittals/downloads/r1494cp.pdf and http://www.cms.hhs.gov/transmittals/downloads/r1738cp.pdf Link to Q&A: http://questions.cms.hhs.gov/app/answers/detail/a_id/8900 ID# 8915 - Published 02/13/2008 Updated 11/06/2009 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) Link to Q&A: http://questions.cms.hhs.gov/app/answers/detail/a_id/8902 Link to Q&A: http://questions.cms.hhs.gov/app/answers/detail/a_id/891 2
ID# 9970 - Published 01/22/2010 Updated 02/19/2010 In CR6440 CMS wrote that: "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." Does this sentence mean that only calls to the patient and family are to be considered for reporting? Because of the nature of a social worker's job, social workers perform a portion of their work without faceto face contact with either the patient or their family, which is why CMS allowed social workers to record their phone calls as visits. For instance, off hours counseling of the patient and/or counseling of family members, who live out of town, would be considered appropriate and necessary when provided via a phone conversation. However, it would be inappropriate to record every phone call that a social worker makes on behalf of a patient. As stated in CR#6440, only social worker phone calls that are necessary for 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 a placement) should be reported. Given the nature of a social worker's job responsibilities, we would expect that almost all social worker phone calls reported would be between the social worker and either the patient or the patient's family. It is feasible, however, that care coordination phone calls by a social worker to other than family members could be reportable. For example, if a SW facilitates alternate care arrangements for the patient in a scenario where the patient's primary caregiver suddenly becomes unavailable to provide care, those calls should be recorded. Clinical judgment should be applied to determine if a particular social worker phone call is reportable. In essence, report only social worker phone calls related to providing care to and/or coordinating care of the patient for the palliation and management of the terminal illness and related conditions, as well as for the counseling of a patient's family, and document those phone calls as such in the clinical records. Link to Q&A: http://questions.cms.hhs.gov/app/answers/detail/a_id/9970 ID# 8910 - Published 02/13/2008 Updated 04/09/2010 Do phone calls and on-call phone consultations constitute a visit for hospice services? With the implementation of CR 6440 on January 1, 2010, hospices may report some social worker calls using revenue code 0569. Please see Q&A #9970 for more details. Hospices may not report any other types of phone calls. (Revised) Reference: http://www.cms.hhs.gov/transmittals/downloads/r1738cp.pdf Link to Q&A: http://questions.cms.hhs.gov/app/answers/detail/a_id/8910 ID# 9916 - Published 11/19/2009 Updated 11/20/2009 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? 3
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. Link to Q&A: http://questions.cms.hhs.gov/app/answers/detail/a_id/9916 ID# 9971 - Published 01/22/2010 Updated 01/27/2010 How should a hospice provider report the total charges field on the line item reporting a visit? The total charges should be the hospice provider's total charges for the service billed on that line of the claim based on the provider's charge structure. What is placed in the charges is completely dependent on the provider and their own charge structure. If a provider charges $100 per visit regardless of the length of the visit, then the charge would be $100 on the line for the visit regardless of the number of units for the length of the visit. If the provider has a timed charge structure then they would report the total charge after calculating their rate for the length of the visit being reported on the claim. Link to Q&A: http://questions.cms.hhs.gov/app/answers/detail/a_id/9971 ID# 9887 - Published 11/03/2009 Updated 11/03/2009 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 increment, a 20 minute visit is counted as 1 increment, and a 25 minute visit is counted as 2 increments. Link to Q&A: http://questions.cms.hhs.gov/app/answers/detail/a_id/9887 ID# 8924 - Published 02/13/2008 Updated 11/06/2009 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) 4
Link to Q&A: http://questions.cms.hhs.gov/app/answers/detail/a_id/8924/kw/visits ID# 8929 - Published 02/13/2008 Updated 11/06/2009 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. Link to Q&A: http://questions.cms.hhs.gov/app/answers/detail/a_id/8929 5