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Change Request 8877

Overview of Changes

Change Request (CR) 8877 External PDFimplements the following four changes for hospice providers, which are effective with dates of services on or after October 1, 2014. Additional information is provided below.

Additional Resources

Diagnosis Code Reporting

The following diagnoses are prohibited from being reported in the primary diagnosis code field on a hospice claim, effective with dates of service on or after October 1, 2014.

  • Debility (ICD-9: 799.3 and 780.79, ICD-10: R53.81)
  • Adult failure to thrive (ICD-9: 783.7, ICD-10: R62.7)
  • Various dementia (ICD-9) codes in the range of 290.0 through 290.9, 293 and 310. See Attachment A External PDFin the CR for a list of all codes. Most ICD-10 dementia codes are those found under the classification, "Mental, Behavioral, and Neurodevelopmental Disorders."

Claims that include one of these diagnosis codes in the primary diagnosis code field will be returned to the provider (RTP) for correction with reason code 30727.

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Q5003 and Q5004 Clarification

This CR clarifies the differences between place of service codes Q5003 and Q5004.

Q5004 is used for patients in a skilled nursing facility (SNF), or hospice patients in the SNF portion of a dually-certified nursing facility. The CR specifies 4 situations in which Q5004 should be reported.

  • The beneficiary is receiving hospice care in a solely-certified SNF.
  • The beneficiary is receiving general inpatient care in the SNF.
  • The beneficiary is in a SNF receiving SNF care under the Medicare SNF benefit for a condition that is unrelated to the terminal illness, and is under routine home care.
  • The beneficiary is receiving inpatient respite care in a SNF.

If the beneficiary is in a nursing facility, but does not meet one of the four situations above, report the place of service as Q5003.

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Timeline for Submitting Notices of Election (NOEs)

Effective October 1, 2014, hospices will be required to submit NOEs within 5 calendar days after the hospice admission date. In order to be considered timely, the NOE must be submitted to and accepted by CGS within 5 calendar days after the hospice admission.

Important Note: If the NOE is submitted timely, but is returned to the provider (RTPd) for correction, the NOE is not considered to be "accepted" and thus, will result in an untimely NOE. Therefore, it is extremely important that hospices verify the information entered on the NOE before submitting it to CGS. In addition, hospices must verify the patient's eligibility information to reduce the risk of a claim RTPing due to an eligibility issue.

NOEs may be returned (RTPd) by the Fiscal Intermediary Standard System when information on the NOE is missing, incomplete or incorrect. In these cases, NOEs are RTPd relatively soon after submission. NOEs may be returned by FISS due to a(n):

  • Missing occurrence code 27 and/or date
  • Invalid physician NPI
  • Incorrect format of a HICN
  • Invalid FROM, TO or ADMIT date
  • Payer code not equal to "Z"

NOEs may also be returned (RTPd) by the Common Working File (CWF) when information on the NOE doesn't match (CWF). NOEs may be RTPd by CWF within a few days, or it may take several days. Therefore, it's very important to check the beneficiary's eligibility information before submitting an NOE. NOEs may be returned by CWF due to a(n):

  • NOE that falls within an open hospice benefit period
  • Beneficiary's name/HIC that does not match CWF
  • Incorrect occurrence code 27 date

Important Note: If an NOE is not corrected out of the RTP file (T B9997) within 5 calendar days after the hospice admission date, it is considered untimely.

If the NOE is untimely:

  • Medicare will not cover or pay for the days of hospice care from the hospice admission to the date the NOE is submitted to, and accepted by, CGS.
  • Hospices must report the days between the date of admission, and the date the NOE was accepted (i.e., receipt date) as non-covered days.
  • Noncovered days are reported with occurrence span code (OSC) 77 and the noncovered dates (date of admission and day before the NOE was received and accepted).
  • Level of care days will need to be entered on separate revenue code lines: noncovered level of care days will be entered on one revenue code line, and all remaining covered level of care days will be entered as usual.

Refer to the "Submitting Claims for Untimely Notices of Election (NOEs)" Web page for details on how to submit your claim when the NOE is untimely.

There are four exceptional circumstances for submitting an untimely NOE. For a list of the exceptional circumstances, and how to submit an exception request claim, refer to the "Requesting an Exception for an Untimely NOE" Web page.

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Notice of Election Termination/Revocation (NOTR)

When a beneficiary is discharged alive, or if a beneficiary revokes his/her hospice benefits, a timely NOTR must be submitted unless a final claim has already been submitted. To be considered timely, the NOTR must be submitted to, and accepted by, CGS within 5 calendar days after the effective date of discharge or revocation.

NOTRs must be submitted to CGS via direct data entry (DDE), meaning it must be keyed directly into the Fiscal Intermediary Standard System (FISS) using Option 49 (NOE/NOA).

For more information on submitting a NOTR, refer to the Hospice Claims Filing webpage, under the header "Notice of Election Termination/Revocation (NOTR) - 8XB."

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Updated: 02.01.17


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