(Medicare Benefit Policy Manual)

Since the decision to utilize this benefit is determined by the beneficiary or the beneficiarys physician, the evaluation and counseling service may not be initiated by the hospice, that is, the entity receiving payment for the service.  Payments by hospi ce agencies to physicians or others in a position to refer patients for services furnished under this provision may implicate the Federal anti- kickback statute.   If the beneficiarys physician is also the medical director or physician employed by a hospice or possesses expertise in the provision of palliative or hospice care, that physician already possesses the expertise necessary to furnish end- of-life services and will have received payment for these services through the use of evaluation and management codes.   For example:   A thoracic surgeon has diagnosed a patient hospitalized in an acute care facility, with end-stage lung cancer with a prognosis of 6 months or less, if the disease runs its normal course.  The patient has been informed of this diagnosis.  The physician, wit h the patients concurrence, requests a consult by the hospitals palliative care team. The team meets with the patient, discusses options, evaluates the patients pain and symptoms, and makes recommendations including hospice care.  Utilization of the eva luation and consultation benefit would be duplicative.   A patient with terminal cervical cancer has been receiving aggressive curative care as an outpatient, which has not been successful.  The patients physician, nurse and social worker have discussed the possibility of hospice.  The patient decides to seek i nformation from a hospice.  Utilization of the evaluation and consultation benefit would be appropriate.   Hospice A receives referrals from various physicians and facilities that the patients are certified as having a terminal illness and wish to elect the hospice benefit.  Hospice A utilizes the evaluation and consultation benefit for every patient as a preli minary evaluation, prior to the actual election of the benefit.  Utilization of the evaluation and consultation benefit would not be appropriate.   Nursing home B contacts Hospice C providing them with a list of patients that can be certified as having a terminal illness.  The medical director of Hospice C makes rounds on these patients, many of whom are unable to communicate and whose symptoms are being managed well.  Utilization of the evaluation and consultation benefit would not be appropriate.   A patient is being treated by a physician for end- stage COPD.  The patient is experiencing distressing symptoms, but has not been able to make any definitive decision as to advanced directive decisions.  The patients physician feels that the expertise of the medical director in Hospice D would be able to provide recommendations as to symptom management and advance directive decisions.  The medical director provides the evaluation and consultation services.  The patient does not elect the hospice benefit, but is able to make determinations as to his wishes and the physician has recommendations to assist in his provision of care. Utilization of the evaluation and consultation benefit would be appropriate.   80.1 - Documentation  (Rev. 188, Issued: 05- 01-14; Effective: 08 -04-14; Implementation: 08 -04-14)  If the beneficiarys physician initiates the request for the evaluation and counseling service, appropriate documentation guidelines should be followed, including the determination of the terminal illness.  Since this provision is not a prerequisite of or part of the hospice benefit, certification of the terminal illness is not required.  The request or referral should be in writing, and the hospice medical director or physician employee would be expected to provide a written note on the patients medical c hart as well as maintaining a written record of this service.   If the beneficiary initiates the request for the service, the hospice agency should maintain a written record of the service and communication with the beneficiarys physician, with the beneficiarys permission, would occur, to the extent necessary to ensure continuity of care.   80.2 - Payment  (Rev.  141, Issued: 03- 02-11, Effective: 01 -01-11: Implementation: 03- 23-11)  Section 512(b) of the MMA amends Section 1814(i)  of the Act  and establishes payment for this service.  The statute specifies that the payment will be made to the hospice for services provided by the hospice medical director or physician employed by the hospice.  The provision of these services may not be delegated to other hospice personnel (i.e., nurse practitioners, registered nurses, social workers, etc.) and may not be furnished by a physician under contract with the hospice.  CMS intends to monitor data regarding the use of this benefit.   Since the evaluation and counseling provision is not a service within the hospice benefit, payment for these services is not included in the hospice payment cap.   Payment to the hospice agency for the provision of this evaluation and counseling service is made using HCPCS code G0337.  The national payment amounts for this service for FY 2005 was $54.57. Future changes in the rate will be identified in the Physician Fee Schedules.  See Pub 100- 04, Medicare Claims Processing Manual, chapter 11, section 10.1, for claims processing instructions.  90  Caps and Limitations on Hospice Payments  (Rev. 246, Issued: 09- 14-18, Effective: 12 -17- 18, Implementation: 12- 17-18)  To ensure that hospice care does not exceed the cost of conventional care, there are two annual limits to hospice payments. The statute requires that hospice payments be limited by an inpatient cap and by an aggregate cap in any given cap year. The cap determinations are calculated on an annual basis.  Any amounts in excess of either cap are considered to be overpayments, and must be repaid to Medicare.   The hospice inpatient cap limits the total number of Medicare inpatient days to no more than 20 percent  of a hospices total Medicare hospice days. The hospice aggregate cap limits the total aggregate payments any individual hospice can receive in a cap year to an allowable amount, based on an annual per beneficiary cap amount & the number of beneficiaries served.   Medicare contractors complete the hospice cap determinations for the inpatient cap after the end of the cap year.  Hospices must file their self -determined aggregate cap determination notice with their Medicare contractor no later than 5 months after the e nd of the cap year and remit any overpayment due at that time.  The Medicare contractor then reconciles all payments at the final cap determination.  If a provider fails to file its aggregate cap determination 5 months after the end of the cap year, paymen ts to the provider are suspended in whole or in part until the self -determined cap is filed with the Medicare contractor.    For the 2016 cap year and earlier, the cap year for the inpatient and aggregate cap runs from November 1st to October 31st.  For the 2018 cap year and later, the cap year for both the inpatient and aggregate cap, as well as the timeframes in which beneficiaries and payments are counted for the purposes of determining each individual hospices aggregate cap aligns with the federal fiscal year (i.e., October 1st to September 30th).    In the year of transition (2017 cap year), for the inpatient cap, the Medicare contractors will calculate the percentage of all hospice days of care that were provided as inpatient days (GIP care and respite care) from November 1, 2016 through September 30, 2017 (11 months).  For the 2017 cap year, hospices using the patient -by-patient proportional method for their aggregate cap determinations should count beneficiaries from November 1, 2016 to September 30, 2017.  For those hospices using the streamlined m ethod for their aggregate cap determinations, hospices should count beneficiaries from September 28, 2016 to September 30, 2017, which is 12 months plus 3 days, in that cap years calculation.  For the counting of hospice payments, hospices using either th e streamlined method or the patient -by-patient proportional method, hospices should count 11 months of payments from November 1, 2016 to September 30, 2017 for the 2017 cap year.  For the 2018 cap year and later, hospices should count both beneficiaries and payments, regardless of whether the streamlined or the patient -by-patient proportional methods are used, from October 1 to September 30.    Hospice Aggregate Cap Timeframes for Counting Beneficiaries and Payments for the Alignment of the Cap Year with the Federal Fiscal Year   Cap year  Beneficiaries  Payments                                         Streamlined method  Patient -by-patient proportional method  Streamlined method  Patient -by-patient proportional method  2016  9/28/15 -9/27/16  11/1/15 -10/31/16  11/1/15 -10/31/16  11/1/15 -10/31/16  2017  (Transition Year)  9/28/16 -9/30/17  (12 months  & 3 days)  11/1/16 -9/30/17  (11 months)  11/1/16 -9/30/17  (11 months)  11/1/16 -9/30/17  (11 months)  2018 and later  10/1-9/30 10/1-9/30 10/1-9/30 10/1-9/30   90.1  Limitation on Payments for Inpatient Care  (Rev. 246, Issued: 09- 14-18, Effective: 12 -17- 18, Implementation: 12- 17-18)  Payments  to a hospice  for inpatient  care are subject  to a limitation  on the  number  of days  of inpatient  care furnished to  Medicare patients.   The total inpatient days reported for both general inpatient and inpatient respite care may not exceed 20% of the total Medicare days reported by the hospice for a cap year.   This  limitation  is applied  once  each year,  at the end of the hospices  cap year.   The inpatient cap  is calculated  by the  Medicare contractor as  follows:   1. The maximum allowable  number  of inpatient  days  is calculated  by multiplying  the total number  of days  of Medicare hospice  care by 0.20.   2. If the  total number  of days  of inpatient  care furnished to  Medicare hospice  patients  is less than  or equal  to the maximum,  no adjustment  is necessary.   3. If the  total number  of days  of inpatient  care exceeds the  maximum allowable  number, the  limitation  is determined  by:   Divide the maximum allowable inpatient days by total inpatient days reported on the Provider Statistical and Reimbursement Report (PS&R). Multiply the resulting ratio against total inpatient care reimbursement reported on the PS&R.    Multiply the excess inpatient care days by the routine home care (RHC) rate, wage adjusted for the location of the hospice.    Add together the amounts calculated in the two bullets above to derive the total allowable payments for inpatient care.    Compare the total allowable payments for inpatient care in bullet 3 above with actual payments made to the hospice for  inpatient  care during the  cap  period" (i.e., the cap year) in order to determine the overpayments paid to the provider.   Any excess  reimbursement  must  be refunded by the  hospice.   EXAMPLE: Assume  that:  40,000 total hospice  days  x 0.20 = 8,000 = the  maximum allowable  inpatient care days.  10,000 inpatient care days  were reported and  paid to the hospice.  The ratio  of maximum allowable days  to the number  of actual  days  equals  8,000 to 10,000 or  0.80.  Assume  the total reimbursement  for inpatient  care revenue  codes  0655 and 0656 (representing Inpatient Respite Care and General Inpatient Care, respectively) for services provided between October 1st and September 30th  is $4,000,000.   $4,000,000 x 0.80 = $3,200,000 = payments for allowable inpatient care days.  Excess inpatient days = (10,000 actual days)  (8,000 allowable days) = 2,000.  Multiply  the excess  inpatient  care days  by the  routine  home  care rate of $192.78, wage adjusted for a hospice located in Redding, California, using the FY 2018 Wage Index value of 1.4968, leading to a wage -adjusted rate of $288.55:   2,000 x $288.55= $577,100= allowable payments for the excess inpatient care days.  Add the allowable inpatient payments and the allowable payments for excess days to derive the inpatient cap: $3,200,000 +  $577,100= $3,777,100= inpatient cap.   Compare  $3,777,100 inpatient  cap with  $4,000,000 actually  paid  for inpatient revenue  codes.