Palmetto GBA Hospice Coalition Questions August 7, 2001 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 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 send an action request for a manual override to the Claims department. A claims associate will override the edit and manually process the claim. Palmetto GBA will forward the question to CMS for additional clarification. 2. How should billing be handled when the recertification is provided outside the 5 days before and 2 days after time frame? Please clarify for both a recertification that was done too early and one that was done too late? 1
A letter from CMS, dated October 18, 1999 states that for all subsequent benefit periods, the hospice must obtain the physician s recertification signed by either the hospice s medical director or physician member of the interdisciplinary group no earlier than 5 days before the recertification date or no later than 2 days after the beginning of the benefit period. If the written recertification cannot be obtained within 2 days, the hospice may obtain a verbal recertification within the 2 days. The written recertification must be on file in the agency before submitting a claim for days in the new benefit period. If a certification is obtained earlier than 5 days before the recertification date, that certification will not qualify as a valid recertification. The hospice would need to obtain a new recertification within the appropriate time frame. If a verbal recertification or the new written recertification is not obtained within 5 days before and 2 days after the beginning of the benefit period, then the agency will not be able to bill for services until the written recertification is received. If that situation occurs, the same procedures listed in Question 1 would need to be followed. Those procedures apply to both recertification situations. A copy of the letter dated October 18, 1999, was requested and has been forwarded to Susan Balfour. 3. If a patient s Medicare number changes during a certification period, do we need to get a new election statement? What other steps would we need to take? If a patient s Medicare number changes during a benefit period, the provider may make a note of the change in the medical records. A provider may verify the change in the Medicare number by using HIQA. After entering the pertinent information, on the first page of HIQA there is a field which indicates Correct and the correct/changed Medicare number would be listed. For billing purposes, if the Common Working File has been updated the claim will process using the incorrect Medicare number and then when the information is verified at CWF the Medicare number will then be changed. The provider would need to make a note of the change and then submit the next bill containing the correct Medicare Number. 4. A patient is in a nursing facility under routine hospice care for lung cancer. The patient develops severe thrombophlebitis that the physician says is not due in any way to management of the lung cancer. The facility places the patient in the skilled care unit for aggressive treatment of the thrombophlebitis and bills Medicare for these days under skilled care. The patient also qualifies for Medicaid. 2
a. Can the hospice team continue to visit, supervise, and bill for the lung cancer under Medicare hospice routine home care while the patient utilizing the Medicare SNF days? b. The facility billed the hospice for the co-pay for room and board. Should the hospice bill Medicaid a room and board charge for these days in order to reimburse the facility for the co-pay or is this the nursing facility's responsibility? While the patient is in the Skilled Nursing Facility for services unrelated to the terminal illness the patient may still remain under the Medicare Hospice Benefit. The Medicaid benefit is considered the secondary payer. If Medicaid will pay for the co-pay, the Skilled Nursing Facility should bill Medicaid. If Medicaid will not pay for the co-pay, then the co-pay is the patient s responsibility. 5. We admitted a patient to our hospice program on 9/14/00. At the time of his admission, the patient had no known insurance coverage. He became eligible for Medicaid during his hospice care. After obtaining an election, we billed Medicaid and received one month s payment but the following month s claim was denied because the patient was now showing Medicare as the primary insurer. After researching the situation, we found the patient had applied for Medicare (unknown to us). Part A became effective in October, retroactive to April 2000--five months prior to him coming on hospice. We do not have a Medicare election and the patient died prior to us becoming aware he had become Medicare eligible. Because the patient was old enough to qualify for Medicare at the time of his admission, we did search HIQA for possible Medicare benefits, but obviously found none. Is there anything we can do now to recoup any payment from Medicare without an election in place? Could Medicaid pay as the secondary payer if Medicare does not? Medicare will not make payment for services for which there is no valid Medicare election. (To prevent this from occurring, many providers follow Medicare election requirements for all non-medicare patients in the event that the patient one day does become Medicare eligible.) Contact your state Medicaid agency for information on any possible Medicaid payments in this situation. 6. Section 418.56, COP Interpretive Guidelines state that Respite is the only type of inpatient care allowed in a NF. Terminology seems to vary from state to state. Please give us the federal definitions for NFs and SNFs. The official definition of a SNF as stated in the Social Security Act, Section 1819 is an institution (or a distinct part of an institution) which: 3
(1) is primarily engaged in providing to residents-- (A) skilled nursing care and related services for residents who require medical or nursing care, or (B) rehabilitation services for the rehabilitation of injured, disabled, or sick persons, and is not primarily for the care and treatment of mental diseases; (2) has in effect a transfer agreement (meeting the requirements of section 1861(l)) with one or more hospitals having agreements in effect under section 1866; and (3) meets the requirements for a skilled nursing facility described in subsections (b), (c), and (d) of this section. In the official definition of a NF as stated in the Social Security Act, Section 1919, the term "nursing facility, means an institution (or a distinct part of an institution) which: (1) is primarily engaged in providing to residents-- (A) skilled nursing care and related services for residents who require medical or nursing care, (B) rehabilitation services for the rehabilitation of injured, disabled, or sick persons, or (C) on a regular basis, health-related care and services to individuals who because of their mental or physical condition require care and services (above the level of room and board) which can be made available to them only through institutional facilities, and is not primarily for the care and treatment of mental diseases; (2) has in effect a transfer agreement (meeting the requirements of section 1861(l)) with one or more hospitals having agreements in effect under section 1866; and (3) meets the requirements for a nursing facility described in subsections (b), (c), and (d) of this section. Such term also includes any facility that is located in a State on an Indian reservation and is certified by the Secretary as meeting the requirements of paragraph (1) and subsections (b), (c), and (d). In addition, section 42 CFR 400-203 further clarifies that a nursing facility "means a SNF or an ICF participating in the Medicaid program". Essentially these two definitions mean that a SNF is a distinct unit in which all beds contained in that unit are Medicare certified beds. All beds in the SNF unit must provide Medicare skilled services as described above in the SSA section 1819. The beds of a SNF can be dually certified as Medicaid beds, but often are not. Most Medicaid beds are in a separate portion of the facility. Beds in the 4
Medicaid portion of the facility are in the Nursing Facility or ICF, which are required to provide a Medicaid level of care as described in the SSA section 1919. Section 1819 of the Social Security Act refers to the Medicare program and Section 1919 of the Social Security Act refers to the Medicaid program. 7. In Georgia, nursing homes bill room and board to Medicaid by submitting the bill to Hospice. Hospice reimburses the nursing home, then submits the bill to Medicaid for reimbursement. Medicaid reimburses the hospice at 95% of the nursing home s room and board charge. The state Department of Human Resources surveyor and the Medicaid office have advised that hospice providers may reimburse nursing homes only the 95% reimbursed to the hospice. However, many providers are paying the nursing home 100% of what the facility would have gotten from Medicaid if the hospice were not involved. For programs that are adhering to the former interpretation, there is an impact on business, as nursing homes will naturally contract with hospice providers that reimburse the full 100%. There is a need for clarification to all providers, so there is consistency in practice. Could Palmetto provide that clarification? Medicare does not cover room and board under the hospice benefit. Please refer the question to your state s Medicaid office. 8. A patient is admitted to hospice and revokes on the 80th day of the first benefit period. In two months, he requests readmission to the hospice program and will be admitted in the second benefit period. In the second benefit period, only one physician needs to sign the Physician Certification of Terminal Illness. Is this true in the event of readmission, or should the hospice have two physicians sign the document? If the patient revoked in the first benefit period and is re-admitted, the medical director of the hospice or the physician member of the hospice IDG and the individual s attending physician should sign the certification of terminal illness. For the subsequent benefit periods, the hospice must obtain the physician s recertification signed by either the hospice s medical director or physician member of the interdisciplinary group. Although not required during subsequent benefit periods, an additional certification from the attending physician can further support the patient s appropriateness for the hospice Medicare benefit. 9. Our community is a border city and is divided between two states. If a hospice is only licensed in one of the two states, but contracts inpatient symptom control and respite care with a hospital in the other state, does the first hospice have to transfer that patient to a hospice licensed in the state where care is now being delivered? 5
Medicare does not require the first hospice to transfer the patient to a hospice licensed in the state where inpatient care is being delivered. Beneficiary Medicare eligibility is applicable in all states. The hospice continues to assume full responsibility for the professional management of the individuals hospice care in accordance with the Hospice Conditions of Participation, and makes arrangements necessary for inpatient care in a participating Medicare or Medicaid facility. An agreement must be in place for services related to the terminal illness. Any staff that travels into the other state would need to be licensed in that state, but the hospice agency itself does not have to be. However, hospice agencies should check with the individual state licensure agency to ensure that any applicable regulations that may govern this situation are met. 10. A nursing facility hospice patient s attending physician is the medical director of the hospice. The physician makes routine visit required for all skilled nursing facility residents. Is this visit billable to Medicare Part A under hospice visit (of course physician will provide some evaluation and management related to terminal illness when seeing patient) or to Medicare Part B as usual since the service is part of requirement as a resident of a facility? If the attending physician is an employee of the hospice or volunteers with the hospice (e.g., medical director or physician member of the interdisciplinary team), the physician's professional services are billed to Medicare Part A by the hospice. The hospice is then responsible for reimbursing the physician. The hospice should reimburse the physician for the technical and administrative component of the service out of their per diem rate as agreed upon in the physician agreement. However, there are many complex implications related to this question that may warrant additional information. 11. Some hospices are providing continuous care for all their patients for the period of time right before death (usually a week or two). Does an actively dying patient automatically qualify for continuous care? Continuous home care is considered appropriate when the patient is experiencing a period of crisis. A period of crisis is defined as a period in which a patient requires predominately nursing care to achieve palliation or management of acute medical symptoms. The hospice must provide a minimum of 8 hours of care in a 24-hour period, which starts and ends at midnight. More that half of the total hours of care provided must be provided by a nurse, and the remaining hours can be supplemented by a home maker or home health aide. Not all patients in the active dying process will meet this criteria, i.e., a need for pain control. However, when the above criteria are met continuous home care may be used for a patient in the active dying process. As an additional note, the example given in the question 6
of a week or two of continuous home care would be unlikely in most situations. The documentation would need to demonstrate that the patient indeed qualified for that level of care the entire time continuous care was provided and billed. 12. Can a hospice choose to donate its hospice services (provide them for charity ) in order to avoid the high expenses of a particular patient? In answering this question, we are strictly interpreting hospice services to meet the same definition as hospice care as defined in the SSA 1861. If a beneficiary qualifies for Medicare and wishes to receive the benefit of hospice services they should elect the Medicare Hospice benefit. When the benefit is elected the hospice agency becomes responsible for all services related to the terminal illness. It would not be appropriate for an agency to provide services for charity to avoid having the patient elect the Medicare Hospice Benefit. In order to provide a more complete answer, additional information is necessary. For example, is the patient a Medicare patient; is the patient hospice eligible? Etc... 13. Please clarify what would a hospice need to document for qualifications of a homemaker? 42 CFR, 418.202(g) states that homemaker services may include assistance in maintenance of a safe and healthy environment and services to enable the individual to carry out the treatment plan. Medicare does not establish standards for the qualifications of homemaker. Check your state s requirements for applicable qualifications. Qualifications may vary from state to state. 14. When a patient enters a hospital for services related to the terminal illness under general inpatient care, how does the hospital bill Medicare for services unrelated to the terminal illness provided during the same stay? For example, patient enters for management of symptoms related to lung cancer, but also receives medications and laboratory tests for heart disease while in the hospital. How does the hospital bill? The hospital should submit their claim for unrelated services to Medicare with a condition code of 07 for Treatment of non-terminal condition for hospice patient. Confirmation was received from our claims department that a hospice claim and the hospital claim with the condition code of 07 will process through the system. The key to the consecutive processing is the use of the 07 condition code, which indicates the services billed by the hospital are unrelated to the terminal condition. 7
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. 16. May a hospice that is part of or related to a hospital provide palliative care services to the hospital patients free of charge? In answering this question, Palmetto GBA interprets palliative care to mean that the patient is not Medicare hospice eligible, and can only advise you concerning those services, which would be billed to Medicare Part A for payment. Hospice agencies should contact their state concerning applicable state regulations that may govern this situation. Additional Information 1. Providers have also indicated that they are not receiving their weekly push messages from the Web site. You need to make sure under your user profile that you have selected the bullet to receive weekly notices. If this bullet is not checked then the provider will not receive the weekly push messages. We will further research the issue with our E-Commerce Department. 2. A request was made concerning the posting of final drafts of the previous Hospice Coalition Questions. The following coalition questions will be posted by 9/19/01: 11/1/99 4/17/00 7/24/00 10/30/00 4/3/01 Due to the web site upgrade some hospice coalition questions were not re-posted to the Web site. We apologize any inconvenience this may have caused. 3. We have requested additional information concerning any additional hospice edits which may be in place. The FMR department has indicated there are no new edits outside of the current edits which are in place for hospice at this time. 8