(Medicare Claims Processing Manual)

 Revocation Ind  no longer used.   Benefit period contain two columns of information.  One captures information on the original billing hospice and any hospice receiving a transfer.  A second column, labelled Owner Change captures information about a change of ownership to either of these  hospices.   Benefit periods are created by submitting claims. Benefit period information supports claims processing functions only, while the election period carries only the beneficiarys election status.  If a hospice needs to cancel all the claims in a benefit period, Medicare systems will remove the hospice benefit period.      The first claim submitted by the hospice after an election must ensure the From and Admission dates match the election period start date. This will ensure the first benefit period in the election is created correctly and subsequent claims will process.  When a hospice submits a Change of Provider/Transfer Notice (TOB 8xC) or a Change of Ownership Notice (TOB 8xE), this will post the Start Date2 and Prov2 information on the hospice benefit period.  When a hospice submits a Change of Ownership Notice (TOB 8xE), this will post an Owner Change start date on the benefit period.      Summary Chart   The following chart provides a reference to help hospices understand which of their submissions will impact an election period or a benefit period.    Effects of Election Periods    Effects of Benefits Periods    Transaction Type  Type of Bill Creates Election Period  Changes Existing Election Period  Removes Election Period  Creates Benefit Period  Changes Existing Benefit Period  Notice of Election Period  8xA Always  OC 56 only Never  Never  Never  Notice of Termination/Revocation  8xB Never  Always  Never  Never  Makes Term Date match revocation date Transfer Notice  8xC Never  Never  Never  Only when no claims have created periods for previous hospice  Always  Void/Cancel of Election  8xD Never  Never  Always  Never  Never  Change of Ownership Notice  8xE Never  Never  Never  Only when no claims have created periods for previous hospice  Always  Admit thru Discharge Claim  8x1 Never  Adds revocation date and rev ind., if not a transfer  Never  Always  Always  Admission Claim  8x2 Never  Never  Never  Always  Always  Continuing Claim  8x3 Never  Never  Never  If OC 27 is present and Through date spans end of current period  Always  Discharge Claim  8x4 Never  Adds revocation date and rev ind., If not a transfer  Never  If OC 27 is present and Through date spans end of current period  Always    30 - Billing and Payment for General Hospice Services  (Rev. 1, 10- 01-03)  30.1 - Levels of Care Data Required on the Institutional Claim to A/B MAC (HHH)  (Rev. 3326, Issued: 08- 14-15, Effective: 01-  01-16, Implementation: 01- 04-16)  With the exception of  payment for physician services, Medicare payment for hospice care is made at one of four predetermined rates for each day that a Medicare beneficiary is under the care of the hospice.  The four rates are prospective rates; there are no retroactive adjustments other than the application of the statutory caps on overall payments and on payments for inpatient care.  The rate paid for any particular day varies depending on the level of care furnished to the beneficiary.   The four levels of care into which each day of care is classified:   Routine Home Care  Revenue code 0651  Continuous Home Care  Revenue code 0652  Inpatient Respite Care  Revenue code 0655  General Inpatient Care  Revenue code 0656   For claims with date of service on or after January 1, 2016, there are two hospice routine home care (RHC) rates.  A hospice day billed at the RHC level in the first 60 days of a hospice election is paid at the high RHC rate.  A hospice day billed at the RHC level on day 61 or later of the hospice election is paid at the low RHC rate.   See section 30.2 of this chapter for additional instructions on the high and low RHC rates.    For each day that a Medicare beneficiary is under the care of a hospice, the hospice is reimbursed an amount applicable to the type and intensity of the services furnished to the beneficiary for that day.  For continuous home care the amount of payment is determined based on the number of hours, reported in increments of 15 minutes, of continuous care furnished to the beneficiary on that day.  For the other categories a single rate is applicable for the category for each day.   For the day of discharge from an inpatient unit, the appropriate home care rate is to be paid unless the patient dies as an inpatient.  When the patient is discharged deceased, the inpatient rate (general or respite) is to be paid for the discharge date.   A description of each level of care follows.   Routine Home Care -  The hospice is paid the routine home care rate for each day the patient is under the care of the hospice and not receiving one of the other categories of hospice care.  This rate is paid without regard to the volume or intensity of routine home care services provided on any given day, and is also paid when the patient is receiving outpatient hospital care for a condition unrelated to the terminal condition.  Continuous Home Care -  The hospice is paid the continuous home care rate when continuous home care is provided in the patients home.  Continuous home care is not paid during a hospital, skilled nursing facility or inpatient hospice facility stay.  This rate is paid only during a period of crisis and only as necessary to maintain the terminally ill individual at home.  The continuous home care rate is divided by 24 hours in order to arrive at an hourly rate.  A minimum of 8 hours must be provided.  Nursing care must be provided for more than half of the period of care and must be provided by either a registered nurse or licensed practical nurse.  Parts of an hour are identified through the reporting of time for continuous home care days in 15 minute increments and these increments are used in calculating the payment rate.  Only patient care provided during the period of crisis is to be reported.  Payment is based upon the number of 15- minute increments that are billed for 32 or more units.  Rounding to the ne xt whole hour is no longer applicable. Units should only be rounded to the nearest increment.  Billing for CHC should not reflect nursing shifts and non- direct patient increments (e.g., meal beaks, report, education of staff). Continuous home care is not intended to be used as respite care.   The hospice provides a minimum of 8 hours of care during a 24- hour day, which begins and ends at midnight.  This care need not be continuous, i.e., 4 hours could be provided in the morning and another 4 hours in the evening, but care must reflect the needs of an individual in crisis.  The care must be predominantly nursing care provided by either a registered nurse (RN) or licensed practical nurse (LPN).  In other words, at least half of the hours of care are provided by the RN or LPN.  Homemaker or home he alth aide (also known as a hospice aide) services may be provided to supplement the nursing care.   Care by a home health aide and/or homemaker may not be discounted or provided at no charge in order to qualify for continuous home care.  The care provided by all members of the interdisciplinary and/or home health team must be documented in the medical record regardless if that care does or does not compute into continuous home care.   For more detailed information on Continuous Home Care, see Pub. 100- 02, Chapter 9, 40.2.1.  Inpatient Respite Care - The hospice is paid at the inpatient respite care rate for each day on which the beneficiary is in an approved inpatient facility and is receiving respite care.  Payment for respite care may be made for a maximum of 5 continuous days at a time including the date of admission but not counting the date of discharge.  Payment for the sixth and any subsequent days is to be made at the routine home care rate.  More than one respite period (of no more than 5 days each) is allowable in a s ingle billing period.  If the beneficiary dies under inpatient respite care, the day of death is paid at the inpatient respite care rate.  Payment at the respite rate is made when respite care is provided at a Medicare or Medicaid certified hospital, SNF, hospice facility, or NF .  General Inpatient Care -  Payment at the inpatient rate is made when general inpatient care is provided at a Medicare certified hospice facility, hospital, or skilled nursing facility.  30.2 - Payment Rates (Rev. 3378, Issued: 10- 16-15, Effective: 01- 01-16, Implementation: 01- 01-16)  The CMS publishes general hospice payment rates annually to be used for revenue codes 0651, 0652, 0655, and 0656.  These rates must then be adjusted by the A/B MAC (A) based on the beneficiarys locality.  National rates are issued as described below.  These rates are updated annually and published in the Recurring Update Notification.  This example is the national rates for October 1, 2004, through September 30, 2005.   Description  Revenue Code  Daily Rate  Wage Amount  Non-weighted Component  Routine Home Care  0651  $121.98  $83.81  $38.17  Continuous Home Care  Full Rate = 24 hours of care;  $29.66 hourly rate  0652  $711.92  $489.16  $222.76  Inpatient Respite Care  0655  $126.18  $68.30  $57.88  General Inpatient Care  0656  $542.61  $347.32  $195.29   For claims with dates of service on or after January 1, 2016, there are two hospice routine home care (RHC) rates.  A hospice day billed at the RHC level in the first 60 days of a hospice election is paid at the high RHC rate.  A hospice day billed at the RHC level on day 61 or later of the hospice election is paid at the low RHC rate. Medicare systems count 60 days from the date of admission regardless of whether some d ays are covered or non-covered.   For a hospice patient that is discharged and readmitted to hospice services within 60 days of the discharge, the hospice days will continue to follow the patient.  If the hospice patient is discharged from hospice care for more than 60 days a new election to hospice will initiate a reset of the patients 60 -day window, paid at the RHC high rate upon the new admission.  Example:    Patient elected hospice for the first time on 01/10/XX.   The patient revoked hospice on 01/30/XX .  The patient re -elected hospice on 02/16/XX.   The patient discharged deceased from hospice care on 03/28/XX.  Since the break in hospice care from 01/30 to 02/16 was less than 60 days the patient day count continues on the second admission.  RHC provided during first election from 01/10 to 01/30 accounts for 21 days that the high RHC rate would apply.  The 60 day count continues with second admission on 2/16 and the high RHC rate would apply for an additional 39 days.  Day 61 begins the low RHC rate on 3/27.  Multiple RHC days are reported on a single line item on the claim.  The line item date of service represents the first date at the level of care and the units represent the number of days.  As a result, both high and low RHC rates ma y apply to a single line item.   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.