(Medicare Benefit Policy Manual)

Provided the above coverage criteria are met, hospices are paid a per diem rate based on the number of days and level of care provided during the election period.  Levels of care are defined as:    Routine home care (refer to 40.2.1); A routine home care day is a day on which an individual who has elected to receive hospice care is at home and is not receiving continuous home care.    Continuous home care (refer to 40.2.1);  A continuous home care day is a day on which an individual who has elected to receive hospice care is not in an inpatient facility (hospital, SNF, or hospice inpatient unit) and receives hospice care consisting predominantly of nursing care on a continuous  basis at home.  Hospice aide or homemaker services or both may also be provided on a continuous basis.  Continuous home care is only furnished during brief periods of crisis and only as necessary to maintain the te rminally ill patient at home.    Inpatient respite care (refer to 40.1.5 and 40.2.2); An inpatient respite care day is a day on which the individual who has elected hospice care receives care in an approved facility on a short -term basis for respite.    General inpatient care (refer to 40.1.5); A general inpatient care day is a day on which an individual who has elected hospice care receives general inpatient care in an inpatient facility for pain control or acute or chronic symptom management which cannot be managed in other settings.  Hospices are expected to furnish the following services to the extent specified by the plan of care for the individual.  The categories listed above are used in billing to describe the acuity of the services furnished.  See Pub. 100- 04, Medicare Claims Pro cessing Manual, Chapter 11, Processing Hospice Claims, for a description of billing procedures.   40.1 - Covered Services  (Rev. 1, 10- 01-03) A3-3143.1, HO -230.1  Appropriately qualified personnel must perform all services, but it is the nature of the service, rather than the qualification of the person who provides it, that determines the coverage category of the service.  The following services are covered hospice services.   40.1.1 - Nursing Care  (Rev.  12400; Issued: 12- 06-23; Effective: 01 -01-24; Implementation : 01-02-24) To be covered as nursing services, the services must require the skills of a registered nurse (RN), or a licensed practical nurse (LPN) or a licensed vocational nurse (LVN) under the supervision of a registered nurse, and must be reasonable and necessary f or the palliation and management of the patients terminal illness and related conditions.  Services provided by a nurse practitioner (NP) who is not the patients attending physician, are included under nursing care. This means that, in the absence of an NP, an RN, LPN, or LVN would provide the service. Since the services are nursing, payment is  encompassed in the hospice per diem rate and may not be billed separately regardless of whether the services are provided by an NP or an RN. The following are examples of some services that traditionally are provided by an RN, which could also be provided by an NP, for which separate payment is not made:  a. A patient with a terminal illness of lung cancer complains of leg pain. In the absence of an NP, an RN would assess the patient.  b. Assessment of pain and or symptoms to determine the need for medications, other treatments, continuous home care, general inpatient care etc. In the absence of an NP, an RN would assess the patient.  c. Administration of medications through intravenous (e.g., PICC, central, etc.), intrathecal or any other means. In the absence of an NP, an RN would administer the medication.  d. Family counseling. In the absence of an NP, an RN, social worker , counselor , marriage and family therapists (MFT) or mental health counselors (MHCs) would provide this service.  e. Providing a home visit for assessment or provision of care to a patient who is not his/her patient. In the absence of the NP, the service would be provided by an RN, LPN or LVN. Therefore, the NP cannot bill separately for the service.   40.1.2 - Medical Social Services  (Rev. 141, Issued: 03- 02-11, Effective: 01 -01-11: Implementation: 03- 23-11)  Medical social services must be provided by a person who meets the criteria given in the Conditions of Participation at 42 CFR 418.114(b)(3) .  Services of these professionals which may be covered include, but are not limited to:   1. Assessment of the social and emotional factors related to the patients illness, need for care, response to treatment and adjustment to care;   2. Assessment of the relationship of the patients medical and nursing requirements to the patients home situation, financial resources and availability of community resources;   3. Appropriate action to obtain available community resources to assist in resolving the patients problem ( NOTE:  Medicare does not cover the services of a medical social worker to complete or assist in the completion of an application for Medicaid because Federal regulations require the State to provide assistance in completing the application to anyone who chooses to apply for Medicaid.);   4. Counseling services that are required by the patient; and  5. Medical social services furnished to the patients family member or caregiver on a short -term basis when the hospice can demonstrate that a brief intervention (that is, two or three visits) by a medical social worker is necessary to remove a clear and dire ct impediment to the effective palliation and management of the patients terminal illness and related conditions.  To be considered clear and direct, the behavior or actions of the family member or caregiver must plainly obstruct, contravene, or prevent  the patients medical treatment.  Medical social services to address general problems that do not clearly and directly impede treatment, as well as long -term social services furnished to family members, such as ongoing alcohol counseling, are not covered.   40.1.3 - Physicians' Services  (Rev. 188, Issued: 05- 01-14; Effective: 08 -04-14; Implementation: 08 -04-14)  A physician must perform physicians' services (as defined in 42 CFR 410.20(b)(1)(1)) , except that the services of the hospice medical director or the physician member of the interdisciplinary group must be performed by a doctor of medicine or osteopathy.  Nurse practitioners may not serve as a medical director or as the physician member of the interdisciplinary group.  Nurse practitioners may not bill for medical services other than those described in 40.1.3.2.  The hospice face -to-face encounter is an administrative requirement related to certifying the terminal illness as required in 1814(a)(7)(D)(i)  of the Social Security Act (the Act).  By itself, it is not billable, as it is considered administrative (see P ub. 100- 04, Medicare Claims Processing Manual, chapter 11, 40.1.1).  However, if a hospice physician, or a hospice nurse practitioner who is also the patients attending physician, provides reasonable and necessary non- administrative patient care during the face- to-face visit, that portion of the visit would be billable.  See section 40.1.3.2 below for additional requirements for billing physician services provided by NPs.  40.1.3.1 - Attending Physician Services  (Rev. 246, Issued: 09- 14-18, Effective: 12 -17- 18, Implementation: 12- 17-18)  The attending physician is a doctor of medicine or osteopathy, a nurse practitioner, or a physician assistant and is identified by the individual, at the time he or she elects to receive hospice care, as having the most significant role in the determinatio n and delivery of the individuals medical care.   The election statement must include the patients choice of attending physician.  The information identifying the attending physician should be recorded on the election statement in enough detail so that it is clear which physician, NP, or PA was designate d as the attending physician.  This information should include, but is not limited to, the attending physicians full name, office address, NPI number, or any other detailed information to clearly identify the attending physician. Hospices have the flexibi lity to include this information on their election statement in whatever format works best for them, provided the content requirements in 42 CFR 418.24(b) are met.  The language on the election form should include an acknowledgement by the patient (or repr esentative) that the designated attending physician was the patients (or representatives) choice.   If a patient (or representative) wants to change his or her designated attending physician, he or she must follow a procedure similar to that which currently exists for changing the designated hospice.  Specifically, the patient (or representative) must fi le a signed statement with the hospice that identifies the new attending physician in enough detail so that it is clear which physician, NP, or PA was designated as the new attending physician. This information should include, but is not limited to, the attending physicians full name, office address, NPI number, or any other detailed information to clearly identify the attending physician.  The statement must include the date the change is to be  effective, the date that the statement is signed, and the patients (or representatives) signature, along with an acknowledgement that this change in the attending physician is the patients (or representatives) choice.  The effective date of the change in attending physician cannot be earlier than the date the statement is signed.  40.1.3.2 - Nurse Practitioners as Attending Physicians  (Rev. 246, Issued: 09- 14-18, Effective: 12 -17- 18, Implementation: 12- 17-18)  A nurse practitioner is defined as a registered nurse who is permitted to perform such services as 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 training, education and experience requirements described in 42 CFR 410.75.  If a beneficiary does not have an attending physician or a nurse practitioner 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 practitioner 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 nurse practitioners to Medicare beneficiaries who have elected the hospice benefit and who have selected a nurse practitioner as their attending physician.  This applies to nurse practitioners without regard to whether they are hospice employees.   Physician services provided by nurse practitioners may be billed to Medicare only if the:    Nurse practitioner is the beneficiary's designated attending physician; and   Services are medically reasonable and necessary; and   Services are performed by a physician in the absence of the nurse practitioner; and  Services are not related to the certification of terminal illness.   If the nurse practitioner is employed by the hospice, the hospice can bill Part A for physician services meeting the above criteria on a hospice claim.  If the nurse practitioner is not employed by the hospice, the nurse practitioner can bill Part B for physician services meeting the above criteria.   Payment for nurse practitioner 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.   Nurse practitioners 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 beneficiar ys 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.   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).