(Medicare Claims Processing Manual)

When services related to a hospice patients terminal condition are furnished under a payment arrangement with the hospice by the designated attending physician, the attending physician must look to the hospice for payment.  In this situation the physicians services are Part A hospice services and are billed by the hospice to its A/B MAC (HHH).   The CWF response contains the periods of hospice entitlement. This information is a permanent part of the notice and is furnished on all CWF replies and automatic notices. A/B MACs (B) use the CWF reply for validating dates of hospice coverage and to resea rch, examine and adjudicate services coded with the GV or GW modifiers.   40.1.3.1 - Care Plan Oversight  (Rev. 4280, Issued: 04- 19-2019, Effective: 07 -21-19, Implementation: 07- 21-19)  Care plan oversight (CPO) exists where there is physician supervision of patients under care of hospices that require complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans. Implicit in the conce pt of CPO is the expectation that the physician has coordinated an aspect of the patients care with the hospice during the month for which CPO services were billed.   For a physician or NP employed by or under arrangement with a hospice agency, CPO functions are incorporated and are part of the hospice per diem payment and as such may not be separately billed.  For information on separately billable CPO services by the attending physician, nurse practitioner, or physician assistant, see Chapter 12, 180 of this manual.  40.2 - Processing Professional Claims for Hospice Beneficiaries  (Rev.10485, Issued: 11- 19-20, Effective: 09 -07-2020, Implementation: 12- 01-2020)   Professional services of attending physicians, who may be nurse practitioners or physician assistants, furnished to hospice beneficiaries are coded with modifier GV: Attending physician not employed or paid under arrangement by the patients hospice provider.  This modifier must be retained and reported to CWF.   A/B MACs (B) processing professional claims shall presume that hospice benefits are not involved unless the biller codes services on the claim to indicate that the patient is a hospice enrollee (e.g. the GV modifier is billed by the attending physician, or  the GW modifier is billed for services unrelated to the patients terminal condition) or the trailer information on the CWF reply shows a hospice election.  The A/B MAC (B) shall use the hospice enrollment trailer information on the CWF reply to examine a nd validate the claim information.   For beneficiaries enrolled in hospice, A/B MACs (B) shall deny any services on professional claim that are submitted without either the GV or GW modifier.  A/B MACs (A) and (B) or DME MACs, shall deny claims for all other services related to the patients terminal condition furnished by individuals or entities other than the designated attending physician.  Such claims include bills for any DME, supplies  or independently practicing  speech -language pathologists  or physical  therapists  that are related  to the terminal condition.  These services  are included in  the hospice  rate and  paid  through the  institutional claim.   DME MACs shall make determinations of relatedness in the same way the A/B MACs Part B do today  based entirely on the presence of the GW modifier and not based on diagnosis coding.  In the event that the claim exceeds the number of allowable modifiers, the DME MAC shall instruct the supplier to use modifier 99 on the line to indicate additional modifiers are reported in the remarks field.  The supplier must include the GW modifier in the claim remarks. Claims that do not contain the GW modifier shall be denied.   40.2.1 - Claims After the End of Hospice Election Period  (Rev. 2258, Issued: 07-  29-11, Effective: 01 -01-12, Implementation: 01- 03-12)  Upon revocation of Medicare coverage of hospice care for a particular election period, an individual resumes Medicare coverage of the benefits waived when hospice care was elected. After revocation, A/B MACs (B) process and pay professional claims for cove red Part B services that hospice employed physicians may furnish.   50 - Billing and Payment for Services Unrelated to Terminal Illness  (Rev. 4280, Issued: 04- 19-2019, Effective: 07 -21-19, Implementation: 07- 21-19)  Any covered  Medicare services  not related  to the treatment  of the terminal condition for which  hospice  care was elected,  and which  are furnished during a  hospice  election  period, may  be billed  by the rendering provider  using professional or institutional claims  for non- hospice  Medicare payment.  On professional claims, these services are coded with the GW modifier service not related to the hospice patients terminal condition.  On institutional claims, these services are coded with condition code 07 Treatment of Non-terminal Condition for Hospice. A/B MACs (A) and (B) process services coded with the GW modifier or condition code 07 in the normal manner for coverage and payment determinations. See the related chapter of the Medicare Claims Processing Manual chapte r for the  type  of service involved (i.e., Chapter 12 for physician services)  for billing  instructions.  If warranted, A/B MACs (A) and (B) may conduct pre -payment development or post -payment review to validate that services billed with the GW modifier or  condition code 07 are not related to the patients terminal condition.  60 - Billing and Payment for Services Provided by Hospices Under  Contractual Arrangements With Other Institutions  (Rev. 1, 10- 01-03) A-02-102  There may be circumstances in which another health care entity may wish to purchase some of the highly specialized staff time or services of a hospice to better meet the needs of their specific patient population. In these cases, the services are not hospice services in terms of Medicare payment but become part of the service package of the provider under whose care the patient is. Examples of such circumstances are provided below.   EXAMPLE 1   A dually eligible Medicare/Medicaid beneficiary enrolled in the Program of All -Inclusive Care for the Elderly (PACE) program for approximately two years has been diagnosed with a life limiting terminal illness with a prognosis of six months or less. In the  course of routine assessments, the PACE provider recognizes that the beneficiary would benefit from the specialized services of a pain management specialist or a grief counselor. The PACE provider would then enter into a contractual arrangement with a Medicare certified hospice to purchase these specialized services. The hospice provider would bill the PACE provider for the services, and the PACE provider would in turn pay the hospice provider directly. Neither provider type would be allowed to bill Medica re separately for the contracted services (which in this example are PACE services and included in the PACE providers capitated rate). In this example, the PACE provider would maintain a medical record on the patient and the hospice provider would submit any documentation related to the care of the PACE patient to the PACE provider.  EXAMPLE 2   A Medicare beneficiary is receiving skilled services from a Medicare certified home health agency (HHA). The beneficiary has been diagnosed with a life limiting terminal illness, but chooses to continue curative treatments, thereby rendering him ineligible  for the Medicare hospice benefit. The beneficiary is experiencing a period of intractable pain, and the HHA wishes to purchase specialized pain control services from the hospice provider. The HHA would then enter into a contractual arrangement with a Medi care certified hospice to purchase specialized nursing services. The hospice would bill the HHA and the HHA would pay the hospice provider directly. Neither provider type would be allowed to bill Medicare separately for the contracted services (which, in t his example, are home health services and therefore included in the HHAs episode payment). In this example, the HHA would maintain a medical record on the patient, and the hospice submits any documentation related to the pain management to the HHA.  EXAMPLE 3   A Medicare beneficiary (non -dual eligible) resides in a skilled nursing facility (SNF) and has a diagnosis of Alzheimers disease. The beneficiarys disease process has progressed to a stage in which he/she can no longer ingest food or fluids. The benefici arys family has been approached by the SNF regarding the placement of a feeding tube and has been told, their loved one may not live much longer. The family is struggling with this concept and has requested assistance from the SNF regarding hospice care and grief counseling. The SNF has provided information about the Medicare hospice benefit to the family, but the patients legal representative has made a decision not to elect hospice care at this time. The SNF does not have a trained grief counselor or full-time social worker on staff, but has a business relationship with a local hospice and has requested the services of a pastoral or grief counselor. The SNF and hospice enter into a contractual arrangement for the provision of grief counseling to this beneficiarys family by a pastoral care counselor. The hospice provider would bill the SNF, and the SNF would pay the hospice provider directly. Neither provider type would be allowed to bill Medicare Part A or B separately for the pastoral care services (which in this example are included in the Medicares Resource Utilization Group or RUG payments to the SNF). The SNF maintains the medical record on this patient and the hospice provider would submit any documentation related to the pastoral care services provided to the SNF.  60.1 - Instructions for the Contractual Arrangement  (Rev. 1, 10-01-03) A-02-102  A contractual agreement between both parties must be on file and available for review by the state survey agency responsible for conducting surveys on behalf of CMS to assess compliance with the relevant conditions of participation for the provider contracting for the hospice services. Where a PACE organization contracts with a hospice organization, the contract, which is reviewed by CMS, must meet the requirements specified in 42 CFR 460.70.  Go to http://www.gpo.gov/fdsys/browse/collectionCfr.action; select the applicable year, choose title42, and select Chapter IV - Centers for Medicare & Medicaid Services and then locate 460.70.  The agreement must specify each of the services to be provided, the credentials required for any of the professionals providing the services, the billing method and payment amounts, and any required documentation.  60.2 - Clarification of the Payment for Contracted Services  (Rev. 1, 10-01-03) A-02-102  In all of the examples provided above, the billing and payment for the services are between each of the providers. It is our expectation that Medicare will not be billed separately for any of the contracted services referred to in the examples provided above.  70 - Deductible and Coinsurance for Hospice Benefit  (Rev. 1, 10- 01-03) HSP 410  70.1 - General  (Rev. 1, 10- 01-03) A3-3142   There is no deductible.  The payment rates have been reduced by a coinsurance amount on outpatient drugs and biologicals, and inpatient respite care as required by law. No other coinsurance or deductibles may be imposed for services furnished to beneficiaries during the period of an election, regardless of the setting of the services. Hospices may charge beneficiaries for the applicable coinsurance amounts only for drugs and biologicals and for inpatient respite care.   The hospice is responsible for billing and collecting any coinsurance amounts from the beneficiary.   70.2 - Coinsurance on Outpatient Drugs and Biologicals  (Rev. 1, 10- 01-03)  The hospice may charge the beneficiary a coinsurance amount equal to 5 percent of the reasonable cost of the drug or biological to the hospice, but not more than $5, for each prescription furnished on an outpatient basis.  The hospice is not required to make this charge but may do so in accordance with the following.   The hospice must establish a drug copayment schedule that specifies each drug and the copayment to be charged. The copayment charges included on the schedule must approximate 5 percent of the cost of the drugs or biologicals to the hospice, up to a $5 ma ximum.  Additionally, the cost of the drug or biological may not exceed what a prudent buyer would pay in similar circumstances.  The hospice must submit this schedule to the A/B MAC (HHH) in advance for approval.   70.3 - Coinsurance on Inpatient Respite Care  (Rev. 4280, Issued: 04- 19-2019, Effective: 07 -21-19, Implementation: 07- 21-19)  The hospice may charge the beneficiary a coinsurance amount  equal to 5 percent of the national Medicare respite care rate, after adjusting the national rate for local wage differences.  This coinsurance is not counted toward the hospital deductible, but it is limited to the same amount.   EXAMPLE    Assume a wage adjusted inpatient respite care rate for the year (as provided by the A/B MAC (HHH)) of $100. The maximum coinsurance rate would be $5.  The hospice may charge any amount up to and including $5 for inpatient respite care only.