(Medicare Benefit Policy Manual)

Hospice nurse practitioners may conduct face -to-face encounters as described in 20.1(5) as part of the certification process, but are still prohibited by statute from certifying the terminal illness.  40.1.3.3  Physician Assistants as Attending Physicians  (Rev. 246, Issued: 09- 14-18, Effective: 12 -17- 18, Implementation: 12- 17-18)  Effective January 1, 2019, Medicare will pay for medically reasonable and necessary services provided by physician assistants (PAs) to Medicare beneficiaries who have elected the hospice benefit and who have selected a PA as their attending physician.  PAs  are paid 85 percent of the fee schedule amount for their services as designated attending physicians.    A physician assistant is defined as a professional who has graduated from an accredited physician assistant educational program who performs such services as he or she is legally authorized to perform (in the State in which the services are performed) in accordance with State law (or State regulatory mechanism provided by State law) and who meets the training, education, and experience requirements as the Secretary may prescribe.  The physician assistant qualifications for eligibility for furnishing service s under the Medicare program can be found in the regulations at 42 CFR 410.74 (c).    If a beneficiary does not have an attending physician, a nurse practitioner, or physician assistant who has provided primary care prior to or at the time of the terminal illness, the beneficiary may choose to be served by either a physician or a nurse prac titioner who is employed by the hospice.  The beneficiary must be provided with a choice of a physician or a nurse practitioner.   Medicare pays for attending physician services provided by physician assistants to Medicare beneficiaries who have elected the hospice benefit and who have selected a physician assistant as their attending physician.  This applies to physician assistants without regard to whether they are hospice employees.   Effective January 1, 2019, Medicare will pay for medically reasonable and necessary services provided by PAs to Medicare beneficiaries who have elected the hospice benefit and who have selected a PA as their attending physician.  PAs are paid 85 percent of  the fee schedule amount for their services as designated attending physicians.    Attending physician services provided by PAs may be separately billed to Medicare only if:   The PA is the beneficiary's designated attending physician; and   Services are medically reasonable and necessary; and   Services would normally be performed by a physician in the absence of the PA, whether or not the PA is directly employed by the hospice; and   Services are not related to the certification of terminal illness.     If the physician assistant is employed by the hospice, the hospice can bill Part A for physician services meeting the above criteria on a hospice claim.  If the physician assistant is not employed by the hospice, the physician assistant can bill Part B for  physician services meeting the above criteria.  PAs are authorized to furnish physician services under their State scope of practice, under the general supervision of a physician; therefore the regulations at 42 CFR 410.150(a)(15) require that payment for  PA services may be made to the employer or contractor of a PA.  Payment for physician assistant services is made at 85 percent of the physician fee schedule amount.  Services that are duplicative of what the hospice nurse would provide are not separately billable.   Since PAs are not physicians, as defined in 1861(r)(1) of the Act, they may not act as medical directors or physicians of the hospice or certify the beneficiarys terminal illness and hospices may not contract with a PA for their attending physician servic es as described in section 1861(dd)(2)(B)(i)(III) of the Act, which outlines the requirements of the interdisciplinary group as including at least one physician, employed by or under contract with the agency or organization.  All of these provisions apply to PAs without regard to whether they are hospice employees.   Physician assistants cannot certify or re -certify an individual as terminally ill, meaning that the individual has a medical prognosis that his or her life expectancy is 6 months or less if the illness runs its normal course.  In the event that a beneficia rys attending physician is a nurse practitioner or a physician assistant, the hospice medical director or the physician member of the hospice IDG certifies the individual as terminally ill.   The hospice face -to-face encounter must be performed by a hospice physician or hospice nurse practitioner.  PAs may not perform the face -to-face encounter.   40.1.4 - Counseling Services (Rev. 141, Issued: 03- 02-11, Effective: 01 -01-11: Implementation: 03 -23-11)  Counseling services are provided to the terminally ill individual and the family members or other persons caring for the individual at home.  Counseling, including dietary counseling, may be provided both for the purpose of training the individuals family or other caregiver to provide care, and for the purpose of helping the individual and those caring for the individual to adjust to the individuals approaching death.  Bereavement counseling is available to the patient and his or her immediate family to p rovide emotional, psychosocial, and spiritual support and services before and after the death of the patient and to assist with issues related to grief, loss, and adjustment for up to 1 year after the patients death.  Also, see 40.5 regarding waivers under certain conditions for making dietary counseling available.   40.1.5 - Short -Term Inpatient Care  (Rev. 10437, Issued: 11- 06-20, Effective: 10 -01-20, Implementation: 12- 09-20)  Short -term inpatient care may be provided in a participating hospital, hospice inpatient unit, or a participating SNF or NF that additionally meets the special hospice standards regarding patient and staffing areas.  Medicare payment cannot be made for inpatient hospice care provided in a VA facility to Medicare beneficiaries eligible to receive Veterans health services.  Services provided in an inpatient setting must conform to the written plan of care.  However, dually eligible veterans residing at home in their community may elect the Medicare hospice benefit.  See  60, Provision of Hospice Services to Medicare/Veterans Eligible Beneficiaries .  Medicare covers two levels of inpatient care: respite care for relief of the patients caregivers, and general inpatient care which is for pain control and symptom management.  General inpatient care (GIP) may only be provided in a Medicare participating h ospital, SNF, or hospice inpatient facility.  Respite care may only be provided in a Medicare participating hospital or hospice inpatient facility, or a Medicare or Medicaid participating nursing facility.  General inpatient care is allowed when the patients medical condition warrants a short -term inpatient stay for pain control or acute or chronic symptom management that cannot feasibly be provided in other settings.  General inpatient care under the hospice benefit is not equivalent to a hospital level of care under the Medicare hospital benefit.  For example, a brief period of general inpatient care may be needed in some cases when a patient elects the hospice benefit at the end of a covered hospital stay.  If a patient in this circumstance continues to need pain control or symptom management, which cannot be feasibly provided in other settings while the patient prepares to receive hospice home care, general inpatient care is appropriate.   Other examples of appropriate general inpatient care include a patient in need of medication adjustment, observation, or other stabilizing treatment, such as psycho- social monitoring.  It is not appropriate to bill Medicare for general inpatient care days for situations where the individuals caregiver support has broken down unless the coverage requirements for the general inpatient level of care are otherwise met.  For a hospice to provide and bill for the general inpatient level of care, the patient must  require an intensity of care directed towards pain control and symptom management that cannot be managed in any other setting.  Respite care is short -term inpatient care provided to the individual only when necessary to relieve the family members or other persons who normally care for the individual at home.  Respite care may be provided only on an occasional basis and may not be reimbursed for more than 5 consecutive days at a time.  Payment for the sixth and any subsequent day of respite care is made at the routine home care rate, and the patient would be liable for room and board.  Respite care cannot be provided to hospice patients who reside in a facility (such as a long term care nursing facility).  Provision of respite care depends upon the needs of the patient and of the patients caregiver, within the limitations given.   Several examples of appropriate respite care for a patient who does not reside in a facility include providing a few days for the caregiver to rest at home, to visit family, attend a wedding, or attend a graduation for a needed break, or providing a few da ys immediately following a GIP stay if the usual caregiver has fallen ill.  See also, section 40.2.2.  Note that hospice inpatient care in an SNF or NF serves to prolong current benefit periods for general Medicare hospital and SNF benefits.  This could potentially affect patients who revoke the hospice benefit.  If a hospice patient receives general inpatient care for 3 days or more in a hospital, and chooses to revoke hospice, then the 3- day stay (although not equivalent to a hospital level of care) would still qualify the beneficiary for covered SNF services.    40.1.6 - Medical Appliances and Supplies  (Rev. 188, Issued: 05- 01-14; Effective: 08 -04-14; Implementation: 08 -04-14)  Medical appliances and supplies may be provided, including drugs and biologicals.  Only drugs as defined in 1861(t) of the Act and which are used primarily for the relief of pain and symptom control related to the individuals terminal illness are covered .  This includes both prescription and over -the-counter drugs as defined in 1861(t) of the Act.  Appliances may include covered durable medical equipment as described in 42 CFR  410.38 as well as other self -help and personal comfort items related to the palliation or management of the patients terminal illness.  Equipment is provided by the hospice for use in the patients home while the patient is under hospice care.  Medical supplies include those that are part of the written plan of care and that are for palliation and management of the terminal illness or related conditions.  40.1.7 - Hospice Aide and Homemaker Services  (Rev. 141, Issued: 03- 02-11, Effective: 01 -01-11: Implementation: 03- 23-11)  A hospice aide is a person who meets the requirements described in the Conditions of Participation.  Hospice aides may provide personal care services.  Aides may also perform household services to maintain a safe and sanitary environment in areas of the home used by the patient, such as changing the bed or light cleaning and laundering essential to the comfort and cleanliness of the patient.  Hospice aides are assigned to a specific patient by a registered nurse who is a member of the interdisciplinary group.  Written patient care instructions for a hospice aide must be prepared by a registered nurse who is responsible for the supervision of a hospice aide.   CMS Conditions of Participation define a qualified homemaker as an individual who meets the requirements described in 42 CFR 418.202(g)  and who has successfully completed hospice orientation addressing the needs and concerns of patients and families coping with a terminal illness.  Homemaker services may include assistance in maintenance of a safe and healthy environment and services to enabl e the individual to carry out the plan of care.  40.1.8 - Physical Therapy, Occupational Therapy, and Speech-Language Pathology  (Rev. 141, Issued: 03- 02-11, Effective: 01 -01-11: Implementation: 03- 23-11)  Physical therapy, occupational therapy, and speech -language pathology services may be provided for purposes of symptom control or to enable the individual to maintain activities of daily living and basic functional skills.  Also, see 40.5 regarding waivers available under certain conditions for provision of these services.   40.1.9 - Other Items and Services  (Rev. 188, Issued: 05- 01-14; Effective: 08 -04-14; Implementation: 08 -04-14)