(Medicare Claims Processing Manual)

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.   The total amount of coinsurance for inpatient respite care for any beneficiary during a hospice coinsurance period may not exceed the amount of the inpatient hospital deductible applicable for the year in which the hospice coinsurance period began.  A hospice coinsurance period begins with the first day for which an election for hospice services is in effect for the beneficiary and ends with the close of the first period of 14 consecutive days on which no such election is in effect for the beneficiary.   EXAMPLE   Mr. Brown elected an initial 90- day period of hospice care. Five days after the initial period of hospice care ended, Mr. Brown began another period of hospice care under a subsequent election. Immediately after that period ended, he began a third period of hospice care under an additional election period. Since these election periods were not separated by 14 consecutive days, they constitute a single hospice coinsurance period. Therefore, the maximum coinsurance for respite care during all three periods of  hospice care may not exceed the amount of the inpatient hospital deductible for the year in which the first period began.   No other coinsurance may be charged by the hospice.   80 - Caps and Limitations on Hospice Payments  (Rev. 2482, Issued: 06- 01-12, Effective: 04 -14-11 for the 2011 Cap Year and Prior Cap Years; October 1, 2011 for the 2012 Cap Year and Subsequent Cap Years; Implementation Date: 07 -02-12)  For information regarding caps and limitations on hospice payments, see Pub. 100- 02, Medicare Benefit Policy Manual, chapter 9, section 90.  90 - Frequency of Billing and Same Day Billing (Rev. 3502, Issued: 04- 28-16, Effective: 01 - 01-16, Implementation: 10- 03-16)  Hospices must bill for their Medicare beneficiaries on a monthly basis.  Monthly billing must conform to a calendar month (i.e. limit services to those in the same calendar month if services began mid -month) rather than a 30 day period which could span two calendar months.  Hospices submitting more than one claim in a calendar month for the same beneficiary will have claims returned beginning on dates of service July 1, 2013.   The only exception to this requirement is in the case of the beneficiary being discharged or revoking the benefit and then later re -electing the benefit during the same month.  The monthly billing requirement applies even if the patient is discharged, revokes, or expires on the first of the next calendar month.  For example, if a pati ent is admitted to hospice on August 8th and revokes the benefit on September 1st, the hospice must submit two claims. A claim is submitted for dates of service August 8 to August 31and a separate claim is submitted with dates of service September 1 to September 1.  Hospice claims should not span multiple months.  Any hospice claim spanning multiple months will be returned to the provider for correction.   In cases where one hospice transfers a beneficiary to another hospice that admits the beneficiary on the same day, each hospice is permitted to bill and each will be reimbursed at the appropriate level of care for its respective day of discharge or admissi on.   100 - Billing for Hospice Denials  (Rev. 2748, Issued: 07- 26-13, Effective: 01 -01-14, Implementation: 01- 06-14)  100.1 - Billing for Denial of Hospice Room and Board Charges  (Rev. 2410, Issued: 02- 03-12, Effective: 07 -01-12, Implementation: 07- 02-12)  Hospice providers wishing to receive a line item denial for room and board charges may submit the charges as non- covered using revenue code 0659 with HCPCS A9270 and modifier GY on an otherwise covered hospice claim.  100.2 - Demand Billing for Hospice General Inpatient Care  (Rev. 2748, Issued: 07- 26-13, Effective: 01 -01-14, Implementation: 01- 06-14)  The Advanced Beneficiary Notice of Non -coverage (ABN), Form CMS -R-131, is issued by the hospice to Medicare beneficiaries in situations where Medicare payment is expected to be denied.  ABN issuance is mandatory when the level of hospice care is determined  to be not reasonable or medically necessary as defined in 1862(a)(1)(A) or 1862(a)(1)(C).  When a Medicare hospice beneficiary has been receiving covered general inpatient care (GIP) and the hospice determines that continued hospice GIP care is not reas onable and medically necessary, the provider must issue an ABN.  Billing instructions for demand bills associated with ABN issuance are provided in this manual in Chapter 1 General Billing Requirements, section 60.4.1 Outpatient Billing with an ABN (Occurr ence Code 32).   Hospices should be aware Medicare may require suspension of any claims using occurrence code 32 for medical review of covered charges associated with an ABN.  A/B MACs (HHH)  reviewing GIP reported on a hospice claim with an ABN provided may conclude the care is not reasonable and medically necessary.  When the A/B MAC (HHH)  makes the non -coverage determination, they must non- cover the GIP line item(s) on the claim.  Hospices may be paid the routine home care (RHC) rate in lieu of the denied GIP service.  Th e A/B MAC (HHH)  adds a line item for RHC (revenue code 0651) for each denied GIP line.  The charges associated with the added RHC line should be the RHC charges the hospice reports on their claim or in the absence of a hospice submitted RHC line item, the A/B MAC (HHH)  shall enter the applicable RHC base rate.   These instructions are not applicable when the beneficiary is not questioning the Medicare coverage but needs a Medicare denial for a secondary payer.  In those cases, the provider should submit a non- covered claim with the condition code 21.   120 - A/B MACs (B)  Responsibilities for Publishing Hospice Information  (Rev. 2258, Issued: 07-  29-11, Effective: 01 -01-12, Implementation: 01- 03-12)  A/B MACs (B) processing professional claims shall, at least annually, include in newsletters and bulletins to physicians and suppliers an explanation of the hospice program and the requirements for billing for physicians who serve as the attending physicia n to a hospice patient.  A/B MACs (B) shall include information on the use of special modifiers that are in effect at that time.  A/B MACs (B) may also publish related material on Web pages.    130 HOSPICE Pricer Program  (Rev. 3930; Issued: 12- 01-17, Effective: 03 -01-18, Implementation: 03- 01-18) Hospice services billed on TOB 081x and 082x are reimbursed based on calculations made by the Hospice Pricer. The Hospice Pricer is a module within Medicare claims processing systems. The Hospice Pricer makes all payment calculations applicable under Hospi ce claims, including all levels of care (Routine Home Care, Continuous Home Care, Inpatient Respite Care, and General Inpatient Care).   Medicare claims processing systems must send an input record to Pricer for all claims with covered visits, and Pricer will return an output record to the shared systems. The following section describes the elements of Hospice claims that are used in the H ospice Pricer and the logic that is used to make payment determinations. The following is presented for A/B MACs (HHH) in order to help understand their Hospice payments and how they are determined.   130.1 Input/Output Record Layout   (Rev. 12083; Issued: 06- 15-23; Effective: 05 -15-23; Implementation: 07- 17-23)  The required data and format for the Hospice Pricer input/output record are shown below:  FIELD NAME  FIELD LAYOUT  POSITION  DESCRIPTION  NPI X(10)  1-10 Input item: The billing provider's National Provider Identifier, copied from the claim.  PROV- NO X(6)  11-16 Input item: The billing provider's CMS Certification Number (CCN), copied from the claim. (FISS crosswalks the CCN based on the NPI submitted by the provider.)  FROM -DATE  9(8) 17-24 Input item: The statement covers period From date, copied from the claim. Date format must be CCYYMMDD.  ADMISSION- DATE  9(8) 25-32 Input item: The admission date, copied from the claim. Date format must be CCYYMMDD.  Filler  x(10)  33-42  PROV-CBSA  X(5)  43-47 Input item: The CBSA code used to wage -adjust inpatient levels of care. Copied from the value code G8 amount on the claim  BENE -CBSA  X(5)  48-52 Input item: The CBSA code used to wage -adjust home levels of care. Copied from the value code 61 amount on the claim  PROV-  WAGE -IND 99V9(4)  53-58 Output item: The wage index value that corresponds to the PROV -CBSA  BENE - WAGE -IND 99V9(4)  59-64 Output item: The wage index value that corresponds to the BENE -CBSA  NA Day 1 Add-on Units  x(2) 65-66 Input item: The number of days from a prior hospice benefit period if identified by CWF as part of the first 60 days of RHC. NA Day 2 Add-on Units  x(2) 67-68 Input item:  Not used  EOL Day 1  Add-on Units  x(2) 69-70 Input item: The sum of the units associated with revenue codes 055x (if G0299 present) and 056x (other than 0569) on the date of death. No units input if the lines are not associated with routine home care (revenue code 0651)