National Government Services, Inc. Medicare Monthly Review Part A and B
A Combined Part A and Part B Newsletter

MMR-2007 11A, November 2007

Billing Instructions Regarding Payment for Hospice Care Based on Location Where Care Is Furnished

Provider Types Affected
Providers who bill Regional Home Health Intermediaries (RHHI) for inpatient hospice care for Medicare beneficiaries.

What You Need to Know
CR 5745, from which this article is taken, instructs hospices how to document where you provide inpatient levels of care. It announces for Routine Home Care (RHC) and Continuous Home Care (CHC) levels of care (revenue codes 651 and 652): 1) National Uniform Billing Committee (NUBC) approval (effective January 1, 2008) of a new value code (value code G8) to identify a facility core based statistical area (CBSA); and 2) the redefinition of value code 61 to apply to residence locations only.

The development of these codes allows you to continue the current practice of billing all hospice services on a single monthly claim, while allowing Medicare to wage adjust the services on that claim accurately under the new the FY 2008 Hospice Wage Index regulation.

You should make sure that your billing staffs are aware of these value code changes for inpatient hospice care.

Background
CR 5745 instructs hospices how to bill for the location where you provide inpatient levels of hospice care.

Currently, not all Medicare payments for hospice services are wage adjusted based on the location where the service is furnished. For example, Medicare now uses the core based statistical area (CBSA) on the hospice facility’s provider file as the basis for the wage adjustment of inpatient hospice levels of care. This assumes that any inpatient levels of care are provided at an inpatient facility (either at the hospice itself or under arrangements with a facility within the same CBSA). Alternatively, Medicare uses the beneficiary’s residence CBSA as the basis for wage adjustment of Routine Home Care (RHC) and Continuous Home Care (CHC) levels of care (revenue codes 651 and 652).

Further, the beneficiary’s residence CBSA (whether or not it is an inpatient setting) is currently reported on the claim using value code 61 (defined by the NUBC as “Location Where Service is Furnished (HHA and Hospice)).” However, while this definition of value code 61 is broad enough to include both home and facility settings, the code itself does not distinguish between the two locations; and there may be circumstances where RHC and CHC are provided in inpatient settings, as these settings may serve as the beneficiary’s place of residence.

Therefore, since hospice providers frequently bill both home and inpatient levels of care on the same claim; if multiple instances of value code 61 were reported, the claim would not distinguish which CBSA code corresponded to which level of care.

While requiring hospices to bill separately for home vs. inpatient levels of care, would meet Medicare’s need in terms of making accurate payment without making a value code change; this could create unnecessary administrative burden on hospices. Moreover, by artificially increasing the number of hospice claims, it would increase Medicare’s administrative costs.

To avoid these impacts, Centers for Medicare &Medicaid (CMS) asked the NUBC to approve a new value code to distinguish a facility CBSA from the currently reported residence CBSA. This code allows you to continue the current practice of billing all hospice services on a single monthly claim while enabling Medicare to wage adjust the services on that claim accurately under the new regulation. The NUBC approved this new code (value code G8) effective January 1, 2008, and also redefined value code 61 to apply to residence locations only. These codes and their definitions are displayed in Table 1, below.

Table 1
NUBC Approved Value Codes for Hospice Care
MLN Matters Number: MM5745 Related Change Request Number: 5745

Important Notes:

• If hospice services are provided to the beneficiary in more than one CBSA area during the billing period, you should report the CBSA that applies at the end of the billing period. This applies for either RHC and CHC (e.g., the beneficiary’s residence changes between locations in different CBSAs); or for general inpatient and inpatient respite care (e.g., the beneficiary is served in inpatient facilities in different CBSAs.)
• On your claims, enter the five digit CBSA, with two trailing zeroes, in the “amount” field (i.e., if the CBSA is 10180, enter 1018000).

Additional Information
You can find more information about billing Instructions for payment for hospice care based on where the care is furnished by going to CR 5745, located at http://www.cms.hhs.gov/Transmittals/downloads/R1352CP.pdf on the CMS Web site. You will find updated Claims Processing Manual, Chapter 11 (Processing Hospice Claims), Section 30.3 (Data Required on Claim to FI) as an attachment to that CR.

If you have any questions, please contact your RHHI at their toll-free number, which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.

Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.