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Hospice Billing FAQs

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How do I know how much to charge Medicare for my services, visits or drugs?
- CMS' policy is for providers to bill Medicare the same that they charge other payers. There are four manual references listed below that support this position.
  
  Medicare Claims Processing Manual (CMS Pub. 100-04) Ch. 25, §75.5 states "The CMS policy is for providers to bill Medicare on the same basis that they bill other payers. This policy provides consistency of bill data with the cost report so that bill data may be used to substantiate the cost report. Medicare and non-Medicare charges for the same department must be reported consistently on the cost report."
  
  Provider Reimbursement Manual, Part 1, Ch. 22
  
  Section 2202 defines "charges" as "the regular rates established by the provider for services rendered to both beneficiaries and to other paying patients. Charges should be related consistently to the cost of the services and uniformly applied to all patients whether inpatient or outpatient. All patients' charges used in the development of apportionment ratios should be recorded at the gross value; i.e., charges before the application of allowances and discounts deductions."
  
  Section 2203 states "To assure that Medicare's share of the provider's costs equitably reflects the costs of services received by Medicare beneficiaries, the intermediary, in determining reasonable cost reimbursement, evaluates the charging practice of the provider to ascertain whether it results in an equitable basis for apportioning costs. So that its charges may be allowable for use in apportioning costs under the program, each facility should have an established charge structure which is applied uniformly to each patient as services are furnished to the patient and which is reasonably and consistently related to the cost of providing the services. While the Medicare program cannot dictate to a provider what its charges or charge structure may be, the program may determine whether or not the charges are allowable for use in apportioning costs under the program."
  
  Section 2204 states "The Medicare charge for a specific service must be the same as the charge made to non-Medicare patients (including Medicaid, CHAMPUS, private, etc.), must be recorded in the respective income accounts of the facility, and must be related to the cost of the service."
  
  Reviewed: 03.21.17
What is the difference between a hospice revocation and a hospice transfer?
- A hospice revocation occurs when a beneficiary chooses to end their hospice care. The beneficiary must sign a revocation form indicating the date they wish the revocation to become effective. When reporting a revocation, the hospice must bill an occurrence code (OC) 42 along with the date the revocation is effective. The OC 42 date must match the "TO" date of the claim. The beneficiary's hospice benefit period that is posted to the Common Working File (CWF) will be updated with a termination date equal to the last day of covered hospice care (i.e. the date reported with OC 42). All remaining days in the hospice benefit period are forfeited.
  
  Note: Effective with dates of service on/after October 1, 2014, Change Request 8877 requires hospices to submit a notice of termination/revocation (NOTR) using a type of bill 8XB within 5 days after a live discharge or revocation, unless a final claim has already been filed.
  
  A hospice transfer is where a hospice patient transfers from one hospice to another. A Medicare beneficiary can change hospices only once per benefit period (90-day or 60-day). The hospice the patient is transferring from must report a patient status code 50 or 51 on their claim. After the transferring hospice has billed their final claim, the receiving hospice must bill a notice of transfer/change (type of bill 81C). When a patient transfers to a different hospice, they continue in the same benefit period, and there is no break in hospice care.
  
  For information on billing revocations or transfers, refer to the 'Discharge or Revocation of Hospice Care' Web page, or the 'Transferring Beneficiary From/To Another Hospice Agency' web page.
  
  Reviewed: 03.21.17
What is the difference between a hospice discharge and a hospice revocation?
- A hospice may discharge a patient if they determine the patient is no longer terminally ill, or if the patient moves outside of the hospice's service area. A hospice may also discharge a patient for cause (patient or staff safety issues). A revocation is a beneficiary's choice to no longer receive hospice care. The beneficiary must sign a revocation form indicating the date they wish the revocation to become effective. To report a revocation, the hospice must bill an occurrence code 42 and the date of revocation on the claim.
  
  Note: Effective with dates of service on/after October 1, 2014, Change Request 8877 requires hospices to submit a notice of termination/revocation (NOTR) using a type of bill 8XB within 5 days after a live discharge or revocation, unless a final claim has already been filed.
  
  For information about discharges or revocations, refer to the 'Discharge or Revocation of Hospice Care' Web page.
  
  Reviewed: 03.21.17
How does a hospice handle a situation where the patient is transferred to another hospice agency that is outside our service area or in another state?
- If the service areas of the two hospices do not meet or overlap, there is a risk that the hospice patient could experience a gap in hospice care while transferring, and the hospice could be financially liable if the beneficiary needs medical care. Therefore, if the patient is traveling outside of the hospice's service area, it is recommended that the hospice discharge the beneficiary so that the beneficiary can access care under their traditional Medicare fee-for-service benefits. To report a hospice discharge because the patient moved out of the hospice's service area, the hospice should report a condition code 52 on their claim.
  
  Note: Effective with dates of service on/after October 1, 2014, Change Request 8877 requires hospices to submit a notice of termination/revocation (NOTR) using a type of bill 8XB within 5 days after a live discharge or revocation, unless a final claim has already been filed.
  
  Once the beneficiary reaches their final destination, they can re-elect hospice care (assuming that they still meet hospice eligibility requirements). The NOE for the new election must be submitted within 5-days after the hospice admission.
  
  Reviewed: 03.21.17
What are Medicare regulations for hospice patients who are transported by ambulance? When is a hospice responsible for the ambulance transport of a patient?
- The Medicare Benefit Policy Manual (CMS Pub. 100-02) Ch. 9 § 40.1.9addresses coverage of ambulance services to hospice patients. This section states:
  
  "Ambulance transports to a patient's home which occur on the effective date of the hospice election (i.e., the date of admission), would occur prior to the initial assessment and therefore prior to the plan of care's development. As such, these transports are not the responsibility of the hospice. Medicare will pay for ambulance transports of hospice patients to their home, which occur on the effective date of hospice election, through the ambulance benefit rather than through the hospice benefit. Ambulance transports of a hospice patient, which are related to the terminal illness and which occur after the effective date of election, are the responsibility of the hospice."
  
  Reviewed: 03.21.17
What do we need to do to make sure our hospice Medicare Secondary Payer (MSP) claims get paid?
- Hospices should ensure any required MSP data, such as condition codes, occurrence codes and dates, value codes and amounts, and payer codes are present at the time the claim is submitted to Medicare. In addition, detailed remarks are important in assisting with the processing of the MSP claim. As a reminder, Notices of Election (NOEs) should never contain MSP information; these should be submitted as if Medicare were the primary payer.
  
  Review the "Medicare Secondary Payer (MSP) Billing and Adjustments" quick resource tool or the Medicare Secondary Payer (MSP) Online Tool for assistance in determining if Medicare is secondary, and for detailed instructions on the data elements required when submitting an MSP claim to Medicare based on the type of primary insurance. The 'Medicare Secondary Payer (MSP)' and 'Submitting Medicare Secondary Payer (MSP) Claims and Adjustments' Web pages also contain helpful information.
  
  In addition, effective for claims received on or after January 1, 2016, Change Request (CR) 8486 implemented changes that allow MSP claims to be entered directly into the Fiscal Intermediary Standard System via direct data entry (DDE). CR 8486 also requires that all MSP claims, submitted via 5010 format or DDE, include Claim Adjustment Segment (CAS) information to ensure proper processing.
  
  Reviewed: 03.21.17
When billing a pre-election evaluation, do I submit the Notice of Election (NOE) before or after the claim has processed?
- Since the pre-election evaluation occurs prior to the election of the hospice benefit, the NOE must be billed after the pre-election evaluation claim has paid. For more information about billing a pre-election evaluation, please refer to the Medicare Claims Processing Manual (CMS Pub. 100-04) Ch. 11 §10.1 and the Medicare Benefit Policy Manual (CMS Pub. 100-02) Ch. 9 § 80.
  
  Reviewed: 03.21.17
Where can I find information on correcting hospice benefit periods?
- To correct hospice benefit period information that was posted incorrectly, access the information on the "Canceling a Notice of Election or Benefit Period" Web page.
  
  Reviewed: 03.21.17
How can I find a listing of mailing addresses and phone numbers for CGS?
- Mailing addresses for various departments within CGS and the Customer Service telephone number for the Home Health and Hospice Provider Contact Center and the Electronic Data Interchange (EDI) department can be found on the 'Home Health & Hospice Contact Information' Web page.
  
  Reviewed: 03.21.17
When can hospices bill Medicare for physician services?
- Physician services that are related to the terminal diagnosis and are professional (hands-on) in nature are billed to CGS when the physician is employed or under arrangement with the hospice. If the services are provided by an independent attending physician, the physician bills the Medicare Part B MAC.
  
  In addition, Medicare pays for attending physician services provided by a nurse practitioner (NP) if the beneficiary selected the NP as their attending physician. In order for NP services to be separately billable, the NP must have been identified by the patient as their attending physician at the time the hospice benefit was elected. For more information about NPs as attending physicians, refer to the Hospice Benefit Policy Manual (Pub. 100-02) Ch. 9, section 40.1.3.2.
  
  For additional information about billing physicians services under hospice, refer to the Billing Hospice Physician and Nurse Practitioner ServicesCGS quick resource tool or the Billing Hospice Physician and Nurse Practitioner Services Web page.
  Reviewed: 03.21.17
When submitting my final claim for a hospice patient who had revoked/been discharged from hospice, I forgot to include the occurrence code (OC) 42. Is this a problem and how do I fix this?
- When a hospice claim is received with a discharge status code other than 30 (still a patient), 40, 41 or 42 (patient deceased), or 50 or 51 (hospice transfer), and there is no occurrence code 42 on the claim, a revocation indicator will be posted to the beneficiary's hospice benefit period posted on the Common Working File (CWF). Therefore, as long as the patient status code is correct to indicate a discharge, a revocation indicator will post.
  
  However, providers should ensure that they are billing their claims accurately, including submission of occurrence code 42 when it is appropriate.
  
  Occurrence code 42 should only be used to indicate a discharge due to a patient revocation. A discharge by the hospice agency would not require the occurrence code 42, but may require a condition code 'H2' (discharged for cause) or condition code '52' (beneficiary moves out of service area).
  
  If an occurrence code 42 was required, but inadvertently omitted, an adjustment (type of bill 8X7) claim should be submitted to add the OC 42 and the date the patient revoked their hospice election benefit. For detailed information on submitting an adjustment, refer to the 'Adjustments/Cancels' Web page.
  
  Reviewed: 03.21.17
What if a discipline visit begins on one date, but is not complete until the next day? What date do I use as the service date (SERV DT)?
- For visits that begin on one calendar day and span into the next day, report one visit using the date the visit ended as the service date. For post mortem visits, only visits that occurred on the date of death prior to midnight can be reported, and the service date would be the date of death.
  
  Reviewed: 03.21.17
How do I report visits provided under a respite or General Inpatient (GIP) level of care?
- Under respite and GIP, only visits provided by hospice staff are reported. Visits by non-hospice staff are not reported.
  
  For visits under respite, each visit is reported on a separate revenue code line, in 15-min. increments. Visits reported include skilled nurse, aide, social worker (including social worker phone calls), physical therapy, speech-language pathology and occupational therapy.
  
  For visits under GIP, the date of service must be considered, due to new reporting requirements mandated by Change Request 8358.
  - For claims with dates of service prior to April 1, 2014, visits under GIP are reported weekly (Sunday-Saturday). Visits reported include skilled nurse, aide, and social worker. Social worker phone calls, physical therapy, speech-language pathology and occupational therapy are not reported.
  - For claims with dates of service on/after April 1, 2014 (or optionally for dates of service January 1, 2014),
    - For visits provided in a SNF or hospital (Q5004, Q5005, Q5007 or Q5008), each visit is line item billed in 15-min. increments. Visits reported include skilled nurse, aide, social worker (including social worker phone calls, physical therapy, speech-language pathology and occupational therapy.
    - For visits provided in an inpatient hospice facility (Q5006), visits are reported weekly (Sunday-Saturday). Visits reported include skilled nurse, aide, and social worker. Social worker phone calls, physical therapy, speech-language pathology and occupational therapy are not reported. Post-mortem visits are also not reported.
  Reviewed: 03.21.17
What is considered a "visit" for Medicare billing purposes?
- To be counted, the visit by discipline (registered nurse, nurse practitioner, licensed nurse, aide, social worker, physician or nurse practitioner) must be reasonable and medically necessary for the palliation and management of the patient's terminal illness and related conditions as described in the plan of care. In addition, social worker visits may also be provided to the beneficiary's family.
  
  Reviewed: 03.21.17
When are social worker phone calls reported on a hospice claim?
- Social worker phone calls are reported when made under routine, continuous or respite levels of care, including those that occur on the date of death. Social worker phone calls should only be reported when they are necessary for the palliation & management of the terminal illness and related conditions, as described in the plan of care. Calls are reported in 15 minute increments.
  
  Under Change Request 8358for services effective April 1, 2014, social worker phone calls are also reported when provided under a GIP level of care, except for those that occur while the patient is in a hospice inpatient facility (Q5006). These calls are not reported.
  
  When reportable, hospice social workers are billed on a line-item basis, with call length reported in 15-minute increments.
  
  For more detailed information on reporting social worker phone calls, refer to the 'Reporting of Hospice Visits' section of the "Medicare Hospice Billing Codes" quick resource tool.
  
  Reviewed: 03.21.17
What level of care do we bill for the day of discharge from hospice care?
- The day of discharge from hospice care is billed at the routine home care.
  
  Reviewed: 03.21.17
What level of care do we bill for the day of discharge from GIP/respite?
- For a live discharge from an inpatient (GIP/respite) unit, the day of discharge is billed at the appropriate home care rate (routine or continuous). If the patient dies as an inpatient, the inpatient rate (GIP or respite) is billed for the date of death.
  
  Reviewed: 03.21.17
How do I submit a claim when the required face-to-face (FTF) encounter is not done timely?
- Change Request (CR) 7478states that when the FTF is not done timely, the hospice is unable to recertify the patient as terminally ill, and the patient would cease to be eligible for the Medicare hospice benefit. In this case, the hospice must discharge the patient from the Medicare hospice benefit by using the most appropriate patient discharge status code. For more information, refer to the "Untimely Face-To-Face Encounter" Web page.
  
  Note: Effective with dates of service on/after October 1, 2014, Change Request 8877 requires hospices to submit a notice of termination/revocation (NOTR) using a type of bill 8XB within 5 days after a live discharge or revocation, unless a final claim has already been filed.
  
  Reviewed: 03.21.17
Would an on call nurse pronouncement visit be considered a post-mortem visit?
- Any time prior to the pronouncement would be reported as an actual visit. Time from the pronouncement and beyond would be reported as a post-mortem visit. Post mortem services should only be reported for the day of death, using the date of death recorded on the death certificate.
  
  Reviewed: 03.21.17
Is the reporting of drugs and post-mortem visits regardless of the level of care or place of service?
- Any drug or post-mortem visit that the hospice provides to the patient will be reported on the claim, regardless of the level of care or place of service with one exception. For visits under GIP in hospice inpatient facility (Q5006), these are reported weekly, and a HCPC is not required; therefore, post-mortem (PM) visits cannot be reported.
  
  Reviewed: 03.21.17
Where is the NDC information reported on the claim? What are the FISS direct data entry (DDE) fields? For 837I electronic claim submissions, which loops and segments must be populated?
- For the 837I transactions, the NDC information is reported in Loop 2410, as follows:
  - Field LIN02, enter the Product ID Qualifier 'N4'
  - Field LIN03, enter the 11-digit NDC code (without hyphens)
  - Field CTP04, enter the quantity
  - Field CTP05, enter one of the following units of measure qualifier:
  For claims entered direct data entry (DDE) into FISS, the NDC is entered on MAP171E. To access this page, go to FISS Page 02 and press the F11 key. NDC codes must be entered on the line(s) that correspond to the line(s) in which the revenue code 0250 was entered.
  
  For paper UB-04 claims, the NDC is reported in the description field (FL43).
  
  Reviewed: 03.21.17
Is TPN considered a medication? What if you add something to the TPN, like Pepcid or Insulin?
- TPN alone, is not considered a medication, and is not reportable. If a medication is added to the TPN, that medication would be reportable.
  
  Reviewed: 03.21.17
How are drugs billed when they are dispensed individually from a med room at a facility?
- When a facility (hospital, SNF, NF, or hospice inpatient facility) uses a system (such as Pyxis) where each administration of a hospice medication is considered a fill for hospice patients receiving care, the hospice shall report a monthly total for each drug (i.e., report a total for the period covered by the claim), along with the total dispensed.
  
  Reviewed: 03.21.17
Compounded medications do not have an NDC code. How will those be reported?
- When reporting compounded medications, hospices should report multi-ingredient compound drugs using revenue code 0250. The hospice should specify the same prescription number for each ingredient of a compound drug according to the 837I guidelines in loop 2410. In addition, provide the NDC for each ingredient in the compound; the NDC qualifier represents the quantity of the drug filled (meaning the amount dispensed) and should be reported as a unit measure.
  
  Reviewed: 03.21.17
My claim was submitted with the KX modifier and the exception request was granted. However, when we did an adjustment to the claim it moved to status/location S B6001 for a non-medical review additional development request (ADR). Should we have removed the KX modifier, or do we need to submit documentation for the exception request again?
- For auditing purposes, the KX modifier should remain on the claim, even when an adjustment is made. Due to system limitations, the adjustment will again request an ADR; however, you do not need to submit documentation for the adjustment. In this situation, please contact the home health and hospice Provider Contact Center (PCC) at 1.877.299.4500 and choose Option 1. The Customer Service Representative will make a referral to the Claims department to release the adjustment to continue processing.
  
  Reviewed: 03.21.17
If the beneficiary elects hospice, and they pass away in the first seven days of being on hospice, will we get the Routine Home Care (RHC) and the Service Intensity Add-On (SIA) payment?
- If the beneficiary has started a new hospice episode of care, the first sixty days will be paid at the RHC high rate (days 1 through 60). If the beneficiary passes away within the RHC "high" rate, the SIA rate will still apply to the visits performed by a Registered Nurse (RN) or social worker as long as the level of care is a routine home care (RHC level of care) day. The SIA payment would be paid in addition to the current per diem rate for the RHC level of care.
  
  Reviewed: 03.21.17
Our hospice agency has been selected to participate in the Medicare Care Choices Model (MCCM) and some claims are being denied with reason code U519H. What do we need to do?
- The reason code U519H explains that the MCCM claim was received, but there was no benefit period established for the dates of service. Even though you are participating in the MCCM, a hospice notice of election (NOE) must still be submitted to establish the hospice benefit period at the Common Working File.
  
  Reviewed: 03.21.17
Is Advance Care Planning (ACP) covered under the Medicare hospice benefit?
- Yes, ACP may be billed under the physician charges revenue code 0657 when appropriate. Physician services that are related to the terminal diagnosis and are professional (hands-on) in nature are billed to CGS when the physician is employed or under arrangement with the hospice. Please refer to the Medicare Claims Processing Manual (Pub. 100-04, Chapter 11 (Processing Hospice Claims), Section 40.1.2) and the CMS Frequently Asked Questions about Billing the Physician Fee Schedule for Advance Care Planning Services for additional information.
  
  New: 03.21.17

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Hospice Billing FAQs

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