(Medicare Claims Processing Manual)

Extending the example above, if the March claim for this patient consisted entirely of RHC days at home, the payment line item would look like this:   Revenue Code   HCPCS  Line Item Date of Service  Units  0651    Q5001   03/01/XX      31  Medicare systems would:    calculate the dates from 3/01 to 3/26 at the high RHC rate,   calculate the dates from 3/27 to 3/31 at the low RHC rate, and  sum these two amounts in the payment applied to this line item.   30.2.1 - Payments to Hospice Agencies That Do Not Submit Required Quality Data  (Rev. 12083; Issued: 06- 15-23; Effective: 05 -15-23; Implementation: 07- 17-23)  Section 3004 of the Affordable Care Act directs the Secretary to establish quality reporting requirements for Hospice Programs.   Penalties for Failure to Report   For fiscal year 2014 through FY 2023, failure to submit required quality data shall result in a 2 percentage point reduction to the market basket percentage increase for that fiscal year.   Beginning with the FY 2024 and for each subsequent year, failure to submit required quality data shall result in a 4 percentage point reduction to the market basket percentage for any hospice that does not comply with the quality data submission requiremen ts for that FY .  Medicare will provide A/B MACs (HHH) with a Technical Direction Letter (TDL) prior to each fiscal year, identifying hospice agencies not meeting the quality data reporting requirements. A/B MACs (HHH) must update the quality indicator in the Provider Outpa tient Specific File for each identified, hospice agency subject to the payment reduction.   30.2.2  Service Intensity Add -on (SIA) Payments  (Rev. 3502, Issued: 04- 28-16, Effective: 01-  01-16, Implementation: 10- 03-16)  Effective for hospice services with dates of service on and after January 1, 2016, a service intensity add -on payment will be made for the social worker visits and nursing visits provided by a registered nurse (RN), when provided during routine home care i n the last seven days of life.  The SIA payment is in addition to the routine home care rate.  The SIA payment is provided for visits of a minimum of 15 minutes and a maximum of 4 hours per day, i.e. from 1 unit to a maximum of 16 units combined for both nursing visit time and/or social worker visit time per day.  In addition, the time of a social workers phone calls is not eligible for an SIA payment.   The SIA payment amount is calculated by multiplying the continuous home care (CHC) rate (per 15 minutes) by the number of units for the combined visits for the day (payment not to exceed 16 units) and adjusted for geographic differences in wages.   EXAMPLE CLAIM:  End of Life (EOL) 7 day SIA:  Billing Period:  12/01/XX  12/09/XX, Patient Status: 40 RHC in home, discharged deceased.   Revenue Code  HCPCS  Line Item Date of Service  Units  0651    Q5001   12/01/XX      9 0551    G0299   12/01/XX      4 0571   G0156  12/02/XX     6 0561    G0155   12/05/XX     4 0571   G0156  12/05/XX     3 0551    G0299  12/06/XX     3 0571   G0156  12/06XX     4 0551   G0299   12/09/XX     4 0561   G0155  12/09/XX     6 0571   G0156  12/09/XX     2  *Visits reported prior to 12/03/XX are not included in the EOL 7 day SIA.  Day 1 of 7, 12/03/XX, no qualifying units reported for the EOL SIA.  Day 2 of 7, 12/04/XX, no qualifying units reported for the EOL SIA.  Day 3 of 7, 12/05/XX, qualifying units are 4.  Day 3 of the EOL SIA payment is stored on the first applicable visit line for that date: 0561 G0155 12/05/XX UNITS 4. Day 4 of 7, 12/06/XX, qualifying units are 3.  Day 4 of the EOL SIA payment is stored on the first applicable visit line for that date: 0551 G0299 12/06/XX UNITS 3. Day 5 of 7, 12/07/XX, no qualifying units reported for the EOL SIA.  Day 6 of 7, 12/08/XX, no qualifying units reported for the EOL SIA.  Day 7 of 7, 12/09/XX, qualifying units are 10.  Day 7 of the EOL SIA payment is stored on the first applicable visit line for that date: 0551 G0299 12/09/XX UNITS 4.  30.3 - Data Required on the Institutional Claim to A/B MAC (HHH)  (Rev. 12083; Issued: 06- 15-23; Effective: 05 -15-23; Implementation: 07- 17-23)  See Pub. 100- 02, Medicare Benefit Policy Manual, chapter 9, for coverage requirements for Hospice benefits.  This section addresses only claims submission.  Before submitting claims, the hospice must submit a Notice of Election (NOE) to the A/B MAC (HHH).  See section 20, of this chapter for information on NOE transaction types. The Social Security Act at 1862 (a)(22) requires that all claims for Medicare payment must be submitted in an electronic form specified by the Secretary of Health and Human Services, unless an exception described at 1862 (h) applies.  The electronic form at required for billing hospice services is the ASC X12 837 institutional claim transaction.     Since the data structure of this transaction is difficult to express in narrative form and to provide assistance to small providers excepted from the electronic claim requirement, the instructions below are given relative to the data element names on the F orm CMS -1450 hardcopy form.  Each data element name is shown in bold type.  Information regarding the form locator numbers that correspond to these data element names is found in Chapter 25.  Because claim formats serve the needs of many payers, some data elements may not be needed by a particular payer.  Detailed information is given only for items required for Medicare hospice claims.  Items not listed need not be completed although hospices may complete them when billing multiple payers.   Provider Name, Address, and Telephone Number   The hospice enters this information for their agency.  Type of Bill   The hospice enters on of the following Type of Bill codes:  081x  Hospice (non- hospital based)  082x  Hospice (hospital based)   4th Digit  Frequency  Definition  0 - Nonpayment/Zero Claims  Used when no payment from Medicare is anticipated.  l - Admit  Through  Discharge  Claim  This code  is used for a bill encompassing  an entire  course of  hospice  treatment for which  the provider  expects  payment  from  the payer,  i.e., no further bills will be  submitted  for this patient.  2 - Interim   First Claim  This code  is used for the first of an expected  series  of payment  bills  for a  hospice  course  of treatment.  3 - Interim  - Continuing  Claim  This code  is used when  a payment  bill for a hospice  course  of treatment has  already  been  submitted  and further bills  are expected  to be submitted.  4th Digit  Frequency  Definition  4 - Interim  - Last Claim  This code  is used for a payment  bill that is the last of a series  for a  hospice  course  of treatment.   The  Through date  of this bill is the discharge  date, transfer date,  or date of death.  7 - Replacement  of Prior  Claim  This code  is used by the provider  when  it wants  to correct  a previously submitted  bill.  This  is the code  used  on the  corrected  or new bill.  8 - Void/Cancel  of a Prior  Claim  This code is used to cancel a previously processed claim.   Statement Covers Period (From -Through)   The hospice shows  the beginning and  ending dates  of the period covered  by this bill in  numeric  fields  (MM -DD-YY).   The hospice does  not show  days  before  the patients  entitlement began.   Statement periods should follow the frequency of billing instructions in section 90.   Patient Name/Identifier  The hospice enters the beneficiarys name exactly as it appears on the Medicare card.   Patient Address  Patient Birth date  Patient Sex   The hospice enters the appropriate address, date of birth and gender information describing the beneficiary.  Admission/Start of Care Date   The hospice enters  the admission  date,  which  must  be the same date as  the effective date of the hospice  election  or change  of election.   The  date of  admission  may  not precede the  physicians  certification  by more  than  2 calendar  days. The admission date stays the same on all continuing claims for the same hospice election.   Patient Discharge Status   This code  indicates  the patients  status  as of the Through date of  the billing  period.  The hospice enters the most appropriate National Uniform Billing Committee (NUBC) approved code.   NOTE:   that patient discharge status code 20 is not used on hospice claims.  If the patient has died during the billing period, use codes 40, 41 or 42 as appropriate.  Medicare regulations at 42 CFR 418.26 define three reasons for discharge from hospice care:  1) The beneficiary moves out of the hospices service area or transfers to another hospice, 2) The hospice determines that the beneficiary is no longer terminally ill or  3) The hospice determines the beneficiary meets their internal policy regarding discharge for cause.   Each of these discharge situations requires different coding on Medicare claims. Reason 1:  A beneficiary may move out of the hospices service area either with, or without, a transfer to another hospice.  In the case of a discharge when the beneficiary moves out of the hospices service area without a transfer, the hospice uses the NU BC approved discharge status code that best describes the beneficiarys situation and appends condition code 52.  The hospice does not report occurrence code 42 on their claim.  This discharge claim will terminate the beneficiarys current hospice benefit period as of the Through date on the claim.  The beneficiary may re -elect the hospice benefit at any time as long they remain eligible for the benefit.   In the case of a discharge when the beneficiary moves out of the hospices service area and transfers to another hospice, the hospice uses discharge status code 50 or 51, depending on whether the beneficiary is transferring to home hospice or hospice in a medical facility.  The hospice does not report occurrence code 42 on their claim.  This discharge claim does not terminate the beneficiarys current hospice benefit period.  The admitting hospice submits a transfer Notice of Election (type of bill 8xC) aft er the transfer has occurred and the beneficiarys hospice benefit is not affected.   Reason 2:  In the case of a discharge when the hospice determines the beneficiary is no longer terminally ill, the hospice uses the NUBC approved discharge status code that best describes the beneficiarys situation.  The hospice does not report occurrence  code 42 on their claim.  This discharge claim will terminate the beneficiarys current hospice benefit period as of the "Through date on the claim.  Reason 3:  In the case of a discharge for cause, the hospice uses the NUBC approved discharge status code that best describes the beneficiarys situation.  The hospice does not report occurrence code 42 on their claim.  Instead, the hospice reports conditi on code H2 to indicate a discharge for cause.  The effect of this discharge claim on the beneficiarys current hospice benefit period depends on the discharge status.