Hospice CPT Coding FAQ

HOSPICE Overview

Hospice care is an alternative treatment approach that is based on recognition that impending death requires a change from curative treatment to palliative care for the terminally ill patient and support for the family. Palliative care focuses on comfort care and the alleviation of physical, emotional and spiritual suffering. Instead of hospitalization, its focus is on maintaining the terminally ill patient at home with minimal disruptions in normal activities and with as much physical and emotional comfort as possible.

A recipient must be terminally ill in order to receive Medicaid hospice care. An individual is considered terminally ill if he or she has a medical prognosis that his or her life expectancy is six months or less if the illness runs its normal course.

Payment of Medical Services Related To The Terminal Illness

Once a recipient elects to receive hospice services, the hospice agency is responsible for either providing or paying for all covered services related to the treatment of the recipient’s terminal illness.

For the duration of hospice care, an individual recipient waives all rights to Medicaid payments for:

• Hospice care provided by a hospice other than the hospice designated by the individual recipient or a person authorized by law to consent to medical treatment for the recipient.

• Any Medicaid services that are related to the treatment of the terminal condition for which hospice care was elected OR a related condition OR that are equivalent to hospice care, except for services provided by: (1) the designated hospice; (2) another hospice under arrangements made by the designated hospice; or (3) the individual’s attending physician if that physician IS NOT an employee of the designated hospice or receiving compensation from the hospice for those services.

Payment For Medical Services Not Related To The Terminal Illness

Any claim for services submitted by a provider other than the elected hospice agency will be denied if the claim does not have attached justification that the service was medically necessary and WAS NOT related to the terminal condition for which hospice care was elected. If documentation is attached to the claim, the claim pends for medical review. Documentation may

• A statement/letter from the physician confirming that the service was not related to the recipient’s terminal illness, or

• Documentation of the procedure and diagnosis that illustrates why the service was not related to the recipient’s terminal illness.

If the information does not justify that the service was medically necessary and not related to the terminal condition for which hospice care was elected, the claim will be denied. If review of the claim and attachments justify that the claim is for a covered service not related to the terminal condition for which hospice care was elected, the claim will be released for payment. Please note, if prior authorization or precertification is required for any covered Medicaid services not
related to the treatment of the terminal condition, that prior authorization/precertification is required and must be obtained just as in any other case.

Once a claim from a non-hospice provider is denied by the Medical Review staff, resubmitted for reconsideration and denied a second time, the only recourse for appeal of the decision is through the official DHH Appeals process. Requests for hearings must be made in writing to the address below and must include an explanation of the reason for the request, the claim(s) in question, and supporting documentation

How do I bill for hospice services?

The following is an excerpt from the “Part B Answer Book” CD-ROM.

Hospice Care: Overview

If  one  of  your  patients  has  a  terminal  illness,  with  about  six  months  or  less  to  live,  your  patient  can  choose  either  standard  Medicare  coverage  or  hospice  care.  When  someone  chooses  hospice  benefits, he/she may continue to rely on a private doctor and at the same time make use of the hospice physician.

As of Aug. 5, 1997, hospice care is available for two 90-day periods and an unlimited number of 60-day periods during the hospice patient’s lifetime.

Hospice services (including those of the hospice physician) are billed under Part A to the intermediary, which pays 100% of Medicare’s approved charges. Services for an attending physician not connected to the hospice are billed to the carrier. Such services by an attending physician should be coded with the GV  modifier

What Medicare Will Pay For

Medicare hospice benefits pay for treatment designed to keep  your patient as comfortable as possible. Attempts  to  cure  the  condition  that  brings  your  patient  to  the  hospice  don’t  fall  under  this  particular benefit. (The carrier’s medical staff makes the decision about what is and isn’t palliative care). However, you can bill Medicare for curative treatment that isn’t part of the terminal condition, just as you ordinarily would, whether you’re the patient’s private doctor or you work for the hospice.

Once hospice coverage is elected, the patient isn’t eligible for Medicare Part B services related to the treatment and management of his terminal illness. One big exception is that professional services of an attending physician may be billed under Part B. To qualify as an attending physician, the patient must identify at the time he elects hospice coverage, the physician (doctor of medicine or osteopathy) who has the most significant role in his/her medical care. The attending physician doesn’t have to be employed by the hospice, and the patient still may be treated by hospice-employed physician.

Two Paths for Reimbursement

You can bill the carrier for treatment and management of a hospice patient’s terminal illness and get paid 80% of the Medicare fee schedule amount (plus the co-insurance and deductible) – as long as you are the attending physician, and you don’t furnish the services under a payment arrangement with the hospice.

When billing Medicare Part B, make sure to indicate the following in item 19 of the Form CMS-1500: “Hospice patient. Dr. ___________ is the attending physician and is not employed by the hospice.”

However,  if  you  furnish  the  services  related  to  a  hospice  patient’s  terminal  illness  under  a  payment arrangement with the hospice, such services are considered hospice services and are billed by the hospice to the fiscal intermediary. (You don’t bill the carrier). Hospice physician services are paid by the hospice intermediary at 100% of Medicare approved charges.

In  order  to  bill  properly  beginning  December  21,  2000,  a  physician  must  certify  that  the  patient  is terminally ill, which is defined as having a medical prognosis of a life expectancy of six months or fewer if the illness runs its normal course

Revoked or Exhausted Benefits

If  the  patient’s  hospice  benefits  have  been  revoked  or  exhausted,  the  carrier  will  pay  all  medically necessary physician services (even to hospice employed physicians) at the regular fee schedule amount .

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