Palmetto GBA Hospice Coalition Questions November 1, 1999 Billing/Reimbursement/FISS 1. The hospice medical director fails to sign a patient's recertification of terminal prognosis in a timely fashion. It is signed 2 weeks after the benefit period expired. Since there was no signed recertification of prognosis for the next benefit period, the hospice stopped billing for services at the end of the benefit period. a. When may the hospice start billing for services, the date the medical director signed the recertification, or 2 days before the date of signature (since it has been established that a signature dated 2 days following the start of a benefit period is acceptable)? b. When does the new benefit period end, 60 days (or 90 days) from when the last benefit period ended, or from when the hospice started billing, based on the medical director's dated signature? c. Would the beneficiary need to sign a new election statement? This question was answered with the assumption that the agency did not obtain a verbal order from the physician. If the hospice does not obtain a verbal order within 2 calendar days following the initiation of hospice care and the certification/re-certification is not signed timely, the Health Care Financing Administration s (HCFA) Publication 21 states in section 201 that no payment is made for the days prior to the certification. The hospice again will be eligible for reimbursement on the day the medical director gives the verbal certification or signs the re-certification. Therefore, the hospice may not bill for the two days preceding the verbal certification or signature. The new benefit period ends 60 days (or 90 days, whichever is applicable) from the expiration of the last benefit period. Even when the re-certification is not signed timely, the Common Working File (CWF) continues to track the benefit periods. The initial notice of election stands, as the patient neither revoked, nor was discharged. Hence, a new election statement would not be necessary. However, if the agency obtains a verbal order within 2 calendar days following the initiation of hospice care, it would be appropriate for the written certification or recertification to only be obtained prior to billing the first claim in the benefit period, according to HCFA Publication 21, Transmittal 55. Coalition Questions & Answers November 1, 1999
2. A patient under a current HMB election period has a secondary insurance that covers prescription medicines with co-pay of $9 per prescription. If the hospice pays the co-pay, may the medications be obtained from this alternative source? The Health Care Financing Administration s Publication 21, Section 230.1, lists medical appliances and supplies, including drugs and biologicals, are covered hospice services. If a hospice patient has Medicare as the primary payer for their hospice services, the provider s per diem would include the related drugs listed in the plan of care and used for relief and symptom control. Secondary insurance is to be billed when a service is not included in the coverage of the hospice Medicare benefit, such as nursing home room and board. 3. Some hospices have been experiencing difficulty with payment for the date of death. Can you please review the critical elements on the claim for the billing period which ends with the date of the patient s death. Specific examples are needed to answer this question. When a claim is submitted and the patient has expired, code the hospice claim the following way: Type of bill- UB-92 Field Locator 4 811/821 or an 814/824 Through date- UB-92 Field Locator 6 Patient s date of death Patient status- Field Locator 22 40, 41, or 42 Providers should not include a 42 occurrence code on a claim with a patient status of 40, 41, or 42. Only use the 42 occurrence code when the patient revokes the hospice benefit or the agency discharges the patient. 4. Transfer patients often lead to confused billing situations. For instance, a patient was recently transferred; the transferring program sent the receiving program a transfer form confirming the transfer. When the receiving hospice submitted their initial claim, it was discovered that the original hospice had filed a revocation with PGBA instead of a transfer notice. Another hospice discharged the transferring patient from service instead of transferring them with the recommendation that the second hospice start over with an admission to their program. Please review the preferred process. Please refer to the Health Care Financing Administration s Publication 21, Section 210 and Palmetto GBA s Training Manual, Section 4.2.4 for information on the documentation for a transfer. 2
The correct billing procedures are as follows for a transfer. The discharging agency: Submit an 811/821 or 814/824 type of bill (field locator 4) Through date (field locator 6) must equal last date the agency provided service Patient status (field locator 22) must equal 01 indicating a discharge from the agency Do not code a 42 occurrence code and date (field locator 32) on the claim The admitting agency: Submit an 81C/82C type of bill (field locator 4) From date (field locator 6) must equal the admit date to agency Admit date (field locator 17) must equal the effective date of the transfer Do not submit any charges on this notification Notes: Agencies do not need to submit the transfer form signed by the patient with the 81C/82C An 81D/82D may be used to delete an incorrectly submitted 81C/82C In the example where the first agency submitted a revocation, the following is the correction process: The first agency must submit an adjustment (8X7) to their last claim to remove the occurrence code 42 and date and use the condition code of D9. Then second agency can submit or update (only through DDE, the return to provider (RTP) claim) the 8XC transfer notification. Effective 12/29/99, when a patient transfers from one agency to another and both agencies provided service on the same day, we will now process and pay both agencies. This change is included in Transmittal 56 of the HCFA Publication 21. 5. Would you also please review the preferred process for billing additional charges after an 815 bill type has already been filed? Different service center representatives have given us different instructions. Use a XX5 type of bill when a revenue code (not a HCPCS/CPT code) was not included on the original claim. This is a late charge bill. If a provider has already submitted a late 3
charge bill and sees a need to make further changes, they should submit an adjustment bill (XX7) to the original claim. This adjustment may be submitted electronically. If the XX5 contains incorrect information, the claim must be cancelled (XX8) and a new XX5 submitted. An XX5 cannot be adjusted nor can more than one XX5 be submitted for a billing period. Physician Billing 6. The October 1999 Medicare Advisory discussed physician billing. If a patient chooses to continue with an existing physician as the attending physician, but the attending physician prefers that the hospice physician manage the pain and related symptoms, can the attending physician bill Part B for his/her services and the hospice bill part A for the hospice physician visits? In the past, it was our understanding that the patient had to choose only one physician as attending and all other physicians were consultants. In this case, would the hospice physician be considered a consultant? When a patient elects the hospice Medicare benefit, they have the right to chose who will be their attending physician. This physician must be listed on the notice of election (NOE) (81A/82A). If this physician was a non-employee with the hospice, his/her professional services would be billed to Medicare Part B. If the physician listed on the NOE was employed with the hospice, the hospice would bill his/her professional services to Medicare Part A on the hospice claim. If the non-employed attending physician preferred another physician employed with the hospice or not employed with the hospice to participate in the care, the hospice would bill the charges to Medicare Part A on the hospice claim. Any physician, who is not the attending physician, should have a contract in place before providing any services to a hospice patient. In this example, the hospice s medical director would be serving as a consulting physician. General 7. HCFA has been sending patients and families "Summary Bulletins" describing the amount of money Medicare has reimbursed the hospice provider for hospice services, and informing the patient/family that they may request an itemized bill from the hospice for services provided. Nowhere on the document does it explain to patients and families that hospice services are reimbursed on a per diem, rather than a fee for service, basis, nor does it explain that the reimbursement is based on average costs for providing care to all patients, rather than on the specific services provided to any individual beneficiary. On the other hand, the document 4
prominently features statements informing patients and families of where they can report fraud. Would there be some way to reformulate these summary documents in a way that better explains to patients and families how the hospice benefit is structured and what they should be expecting? This question was answered with the assumption that the reference to Summary Bulletins is referring to the Medicare Summary Notice (MSN). This statement notifies beneficiaries of all services rendered under the Medicare benefit. The MSN includes information pertaining to all lines of business. Palmetto GBA does not control the formatting of the MSN. Suggestions can be made to HCFA concerning the reformatting of the MSN to better explain what is being reimbursed by Medicare for hospice services. As stated in the Program Memorandum AB-99-25, Medicare beneficiaries have the right to request and receive an itemized statement from the health care provider of service. If the beneficiary requests such information from the hospice provider, the hospice provider should adhere to the request thus furnishing the information pertaining to the different levels of care provided to the hospice beneficiary. At this point the provider could educate the beneficiary that hospice services are reimbursed on a per diem basis rather than a fee for service, and that reimbursement is based on average costs for providing care to all patients rather than on the specific services provided to any individual beneficiary. Included is a copy of the Program Memorandum AB-99-25. 8. A hospice agency is considering having their medical records copied onto CD- ROM. If that were done, would the provider still have to preserve the original hard copies medical records or could they be destroyed? If the hard copies do need to be preserved, for how many years? Please give regulatory and/or statutory cites which would address this situation. According to the 42 CFR 405.750 regarding reopenings, an Intermediary may ask for medical records as far back as 4 years. So for Medicare purposes, an agency will need to produce the records in the event an audit would occur. Providers should also check with their individual state survey office. The state generally dictates the period of time the hard copies must be kept. 9. What FMR edits are planned for the coming year? At this time there are no new edits specific to hospice planned. Palmetto GBA will continue data analysis, and make decisions based on that analysis regarding edits set in the future. 10. What types of hospice issues and /or concerns are the Congressional Liaisons running in to? 5
The congressional unit has received very few congressional inquiries over the last few months relating to the hospice benefit. We did have one question regarding the increase in the wage index for Illinois and another seeking more information regarding the denial of a hospice claim. A few of the others were requests for information about obtaining coverage for hospice care. Late Question: 11. It seems to be getting increasingly difficult to log onto the Bulletin Board System (BBS) to submit production claims and to download reports. Is there a problem that you are aware of, or is this simply related to the number of users logging on during peak hours? No problems with the BBS have been reported. We are not having a customer-wide problem. If providers are experiencing difficulties, please contact the EDI Help Desk at (803) 736-4730, option 3 or (803) 788-9751. 6