evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Hospice election and revocation date information are stored in a separate election period in Medicare systems from benefit period information, so the two types of information can be changed independently. Both election periods and benefit periods are store d in Medicares Common Working File (CWF) and can be viewed via inquiry screens.  When a hospice submits an NOE (TOB 8xA), Medicare systems create an election period.  The election period file for each beneficiary contains the following data elements for each of their election periods:    Period Number  a sequential number assigned to each election period     Elect Date  the date of election reported in the From date of the NOE    Receipt Date  the receipt date of the NOE that created the election period    Revoc Date the revocation date reported in the Through date of the NOTR or of a discharge claim    Revoc Ind  a revocation indicator assigned when the revocation date is recorded    Provider  the CMS Certification Number (CCN) of the hospice that submitted the NOE    NPI  the National Provider Identifier of the hospice that submitted the NOE.  When an 8xA is processed, the election date and receipt date will be updated on the election period CWF inquiry screen.  The revocation date remains blank and the revocation indicator is 0.   The NOE receipt date will be retained on the election period permanently. If benefit periods are cancelled, this will not remove the NOE receipt date from Medicare systems. If the election date is changed using the occurrence code 56/condition code D0 proc ess described above, the NOE receipt date will not change.  When a hospice submits an NOTR (TOB 8xB), Medicare systems will post a revocation date on the election period and change the revocation indicator to 1.  Similarly, if a revocation date is corrected using the 56/D0 process, the correct date will be displaye d on the election period.   If the hospice files the discharge claim in lieu of the NOTR, the claim will also post the revocation date and revocation indicator on the election period, in addition to updating the Term Date1 of the benefit period to match the revocation date.
(Medicare Claims Processing Manual)
A later NOE for the same beneficiary when there is no revocation date on the election period will be rejected.  Consistent submission of revocations, via NOTRs or claims, within 5 days of the revocation date as required by regulation, is very important to prevent this.   When a hospice submits a Change of Provider/Transfer Notice (TOB 8xC) or a Change of Ownership Notice (TOB 8xE), this will make no changes to the election period.  Benefit Periods   The hospice benefit period file pre -existed the episode period file and retains all the same fields it had historically, but election -related fields on those screens will no longer be used.   The hospice benefit period file for each beneficiary contains the following data elements for each of the benefit periods they use while receiving hospice care:    Start Date1  the start date of the benefit period    Term Date1 -- the end date of the benefit period    Prov1 -- the CCN of the hospice whose claim created the benefit period    Inter1 a number identifying the Medicare Administrative Contractor serving Prov1   DOEBA Date  date of earliest billing activity, the first date billed in the period    DOLBA Date  date of latest billing activity, the Through date of the last claim processed in the period.    Days Used  the number of days in the period used to date    Start Date2  the effective dates of a transfer during the period    Prov2 -- the CCN of the hospice from the 8xC transfer notice.    Inter2 -- a number identifying the Medicare Administrative Contractor serving Prov1   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.
(Medicare Claims Processing Manual)
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)
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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.
(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)
(Medicare Claims Processing Manual)
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
(Medicare Claims Processing Manual)
*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.
(Medicare Claims Processing Manual)
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)