(Medicare Claims Processing Manual)

For example, assume that a nurse arrives at the home at 9 pm to provide routine home care (RHC) to a dying patient, and that the patient passes away at 11 pm.  The nurse stays with the family until 1:30 am.  The hospice should report a nursing visit with e ight 15-minute time units for the visit from 9 pm to 11 pm.  On a separate line, the hospice should report a nursing visit with a PM modifier with four 15- minute time units for the portion of the visit from 11 pm to midnight to account for the 1 hour post mortem visit.   If the patient passes away suddenly, and the hospice nurse does not arrive until after his death at 11:00 pm, and remains with the family until 1:30 am, then the hospice should report a line item nursing visit with a PM modifier and four 15- minute incremen ts of time as the units to account for the 1 hour post mortem visit from 11:00 pm to midnight.   The following modifier may be used to identify requests for an exception to the consequences of not filing the NOE timely:   KX -  Even if a hospice believes that exceptional circumstances beyond its control are the cause of its late -filed NOE, the hospice shall file the associated claim with occurrence span code 77 used to identify the non- covered, provider liable days.  The hospice shall also report a KX modifier with the Q HCPCS code reported on the earliest dated level of care line on the claim.  The KX modifier shall prompt the A/B MAC (HHH) to request the documentation supporting the request for an exception.  Based on that documentation, the A/B MAC (HHH) shall determine if a circumstance encountered by a hospice qualifies for an exception.  If the request for an exception is approved by the A/B MAC (HHH), the A/B MAC (HHH) shall process the claim with the CWF override code and remove the submitted provider liable days, which will allow payment for the days associated with the late -filed NOE.  If the A/B MAC (HHH) finds that the documentation does not support allowing an exceptional circumstance, the A/B MAC (HHH) shall process the claim as submitted.  The contractor shall use the following remittance advice messages and associated codes under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three  Group Code: CO  CARC: 96  RARC: MA54  MSN: N/A  Hospices may appeal the contractors determination that an exceptional circumstance did not apply. Modifier GV may be used to identify attending physician services performed by a doctor of medicine, doctor of osteopathy, nurse practitioner or physician assistant .  Service Date   The HIPAA standard 837 Institutional claim format requires line item dates of service for all outpatient claims.  Medicare classifies hospice claims as outpatient claims (see Chapter 1, 60.4).    Service date reporting requirements will vary between continuous home care lines (revenue code 652) and other revenue code lines.   Revenue code 652  report a separately dated line item for each day that continuous home care is provided, reporting the number of hours, or parts of hours rounded to 15-minute increments, of continuous home care that was provided on that date.  Other level of care revenue codes  report a separate line for each level of care provided at each service location type, as described in the instructions for HCPCS coding reported above.  Hospices report the earliest date that each level of care was provi ded at each service location.  Attending physician services should be individually dated, reporting the date that each HCPCS code billed was delivered.   Service reporting revenue codes  report dates as described in the table above under Revenue Codes.   For service visits that begin in one calendar day and span into the next calendar day, report one visit using the date the visit ended as the service date.   Service Units   The hospice enters  the number  of units  for each  type  of service.   Units  are measured  in days for revenue codes  651, 655, and  656. , Units for revenue code 652 are reported in 15-minute increments.   When days are non -covered due to not filing a timely NOE, the hospice reports two lines for the affected level of care.  For example, if a billing period contains 31 days of routine home care and the first 5 days are non -covered due to not filing a timely NOE:   The hospice reports one revenue code 0651 line containing the earliest non-covered date of service, 5 units and all non- covered charges   The hospice reports a second revenue code 0651 line containing the first covered date of service, 26 units and all covered charges.    Report units for service reporting lines as a multiplier of the visit time defined in the HCPCS description.   When the revenue code or HCPCS code requires 15 -minute increment reporting, visits of any length are to be reported, rounding the time to the nearest 15- minute increment.   For dates of service on and after 10/1/2018, units for summary drug charges lines may be reported using 1 to satisfy the required field or using a number of drugs provided during the billing period, at the option of the hospice.  Service unit data will n ot be used by Medicare for payment or data analysis.   Total Charges   The hospice enters the total charge for the service described on each revenue code line.  This information is being collected for purposes of research and will not affect the amount of reimbursement.  Non-Covered Charges   The hospice enters a charge amount equal to the Total Charges for any revenue code line with a Service Date within a non -covered period (e.g., an occurrence span code 77 period).   Payer Name   The hospice identifies the appropriate payer(s) for the claim.   National Provider Identifier  Billing Provider   The hospice enters its own National Provider Identifier (NPI).   Principal Diagnosis Code   The hospice enters diagnosis coding as required by ICD-9- CM / ICD -10-CM Coding Guidelines.  CMS accepts only HIPAA approved ICD-9- CM or ICD -10-CM/ICD -10-PCS codes, depending on the date of service.  The official ICD-9-CM codes, which were updated annually through October 1, 2013, are posted at http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/codes.html  The official annual updates to ICD-10-CM and ICD-10- PCS codes are posted at http://www.cms.gov/Medicare/Coding/ICD10/index.html. Use full diagnosis codes including all applicable digits, up to five digits for ICD-9- CM and up to seven digits for ICD-10- CM.  The principal diagnosis listed is the diagnosis most contributory to the terminal prognosis.  Non-reportable Principal Diagnosis Codes to be returned to the provider for correction:    Hospices may not report ICD-9CM v- codes and ICD -10-CM z -codes as the principal diagnosis on hospice claims.  Hospices may not report debility, failure to thrive, or dementia codes classified as unspecified as principal hospice diagnoses on the hospice claim.  Hospices may not report diagnosis codes that cannot be used as the principal diagnosis according to ICD-9- CM or ICD -10-CM Coding Guidelines or require further compliance with various ICD-9- CM or ICD -10-CM coding conventions, such as those that have principal diagnosis code sequencing guidelines.  Other Diagnosis Codes  The hospice enters diagnosis coding as required by ICD-9-CM and ICD-10-CM Coding Guidelines.  Hospices will report all diagnoses identified in the initial and comprehensive assessments on hospice claims, whether related or unrelated  to the terminal prognos is of the individual effective October 1, 2015. This will also include the reporting of any mental health disorders and conditions that would affect the plan of care.  Attending Provider Name and Identifiers   The hospice enters  the National Provider Identifier (NPI) and name of  the physician currently  responsible  for certifying  the terminal illness , and signing the  individuals  plan  of care for medical  care and treatment.   The hospice shall enter the NPI and name of the attending physician designated by the patient as having the most significant role in the determination and delivery of the patients medical care. If there is no attending physician listed, then the hospice s hall report the certifying MD.  Other Provider Name and Identifiers   If the attending physician is a nurse practitioner or physician assistant, the hospice enters the NPI and name of the nurse practitioner or physician assistant. The hospice enters the NPI and name of the hospice physician responsible for certifying that the patient is terminally ill, with a life expectancy of 6 months or less if the disease runs its normal course.  Note:  Both the attending physician and other physician fields should be completed unless the patients designated attending physician is the same as the physician certifying the terminal illness.  When the attending physician is also the physician certifying the terminal illness, only the attending physician is required to be reported. NOTE:  for electronic claims, this information is reported in Loop ID 2310F  Referring Provider Name.   Hospices shall report the NPI of any nursing facility, hospital, or hospice inpatient facility where the patient is receiving hospice services, regardless of the level of care provided when the site of service is not the billing hospice.  The billing hospi ce shall obtain the NPI for the facility where the patient is receiving care and report the facilitys name, address and NPI on the 837 Institutional claim format in loop 2310 E Service Facility Location.  When the patient has received care in more than on e facility during the billing month, the hospice shall report the NPI of the facility where the patient was last treated.  Failure to report this information for claims reporting place of service HCPCS Q5003 (long term care nursing facility), Q5004 (skilled nursing facility), Q5005 (inpatient hospital), Q5007 (long term care hospital) and Q5008 (inpatient psychiatric facility) will result in the claim being returned to the provider.     30.4 - Claims From Medicare Advantage Organizations  (Rev. 2258, Issued: 07- 29 -11, Effective: 01-01-12, Implementation: 01-03-12)  Federal regulations require that Medicare fee -for-service A/B MACs (HHH) maintain payment responsibility for managed care enrollees who elect hospice.  These regulations are found at 42 CFR Part 417, Subpart P:go to http://www.gpo.gov/fdsys/browse/collectionCfr.action; select the applicable year, and scroll down to Part  417, and go to 42 CFR 417.585 Special Rules: Hospice Care (b) ; and  also at 42 CFR 417.531 Hospice Care Services (b)  which can be located in the same manner .  Medicare Fee for Service retains payment responsibility for all hospice and non-hospice related claims beginning on the date of the hospice election.  A. Covered Services   While a hospice election is in effect, certain types of claims may be submitted by either a hospice provider, or a provider treating an illness not related to the terminal condition, to a fee -for-service A/B MAC (A), (B), or (HHH) of CMS.  These claims are  subject to the usual Medicare rules of payment, but only for the following services:  1. Hospice services covered under the Medicare hospice benefit if billed by a Medicare hospice;   2. Services of the enrollees attending physician if the physician is not employed by or under contract to the enrollees hospice;   3. Services not related to the treatment of the terminal condition while the beneficiary has elected hospice; or   4. Services furnished after the revocation or expiration of the enrollees hospice election until the full monthly capitation payments begin again.  Monthly capitation payments will begin on the first day of the month after the beneficiary has revoked their hospice election.   B. Billing of Covered Services   Medicare hospices bill the Medicare fee- for-service A/B MAC (HHH) for beneficiaries who have coverage through Medicare Advantage just as they do for beneficiaries with fee-for-service coverage.  Billing begins with a notice of election for an initial hospi ce benefit period, and followed by claims with types of bill 81X or 82X.  If the beneficiary later revokes election of the hospice benefit, a final claim indicating revocation, through use of occurrence code 42, should be submitted as soon as possible so t hat the beneficiarys medical care and payment is not disrupted.  Medicare physicians may also bill the Medicare fee- for-service A/B MAC (HHH) for beneficiaries who have coverage through Medicare Advantage as long as all current requirements for billing for hospice beneficiaries are met.  These claims should be submitted  with a GV or GW modifier as applicable.  A/B MACs (HHH) process these claims in accordance with regular claims processing rules.  When these modifiers are used, A/B MAC (HHH) are instructed to use an override code to assure such claims have been reviewed and should be approved for payment by the Common Working File in Medicare claims processing systems.