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 Medicare Monthly Review Part A and B
A Combined Part A and Part B Newsletter
MMR-2008 03AB, March 2008

MLN Matters. . .Information for Medicare Providers
(Issued by the Centers for Medicare & Medicaid Services)

Instructions for Reporting Hospice Services in Greater Line Item Detail

MLN Matters Number: MM5245 Revised
Related Change Request (CR) #: 5245
Related CR Release Date: July 28, 2006
Effective Date: January 1, 2007
Related CR Transmittal #: R1011CP
Implementation Date: January 2, 2007

Note: This article was revised on January 24, 2008, to add references to related Change Requests (CRs) 5567 (Reporting of Additional Data to Describe Services on Hospice Claims ) and CR5745 (Billing Instructions Regarding Payment for Hospice Care Based on Location Where Care is Furnished) in the Additional Information section below. All other information remains the same.

Provider Types Affected
Hospices submitting claims to Medicare regional home health intermediaries (RHHI) for hospice services provided to Medicare beneficiaries.

Impact on Providers
This article is based on Change Request (CR) 5245, which provides billing instructions for hospices, as well as requirements for RHHIs concerning billing for continuous home care services on separately dated line items in 15-minute time increments. It also includes information on reporting Healthcare Common Procedure Coding System (HCPCS) codes to identify the service location of all hospice levels of care.

Background
Historically, billings by institutional providers to the Centers for Medicare & Medicaid Services (CMS) fiscal intermediaries (FI) contained limited service line information. Claim lines on a typical institutional claim in the 1980s or early 1990s may have reported only the following:

Over the last ten years, legislated payment requirements have changed, and CMS has implemented increasingly complex payment methods. These changes have required more line item detail on claims for most institutional provider types, such as:
This detail has supported the payment requirements of legislated payment systems and also improved the quality and richness of CMS analytic data files. However, hospice claims have been an exception to this process. Since the inception of the hospice program in 1983, hospices have been required to submit on CMS claims only a small number of service lines to report the number of days at each of the four Hospice levels of care, and HCPCS coding was required only to report procedures performed by the beneficiary’s attending physician (if that physician was employed by the hospice). This limited claims data has restricted CMS’s ability to ensure optimal payment accuracy in the hospice benefit, and to carefully analyze the services provided in this growing benefit. Therefore, effective January 1, 2007, CMS will require hospices to report additional detail on their claims.

A hospice is paid a continuous home care (CHC) rate when CHC is provided. This rate is paid: The CHC rate is divided by 24 hours in order to arrive at an hourly rate, and a minimum of eight hours must be provided. The CHC need not be continuous, i.e., four hours could be provided in the morning and another four hours in the evening, but the 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 health aide services may be provided to supplement the nursing care.

Note: Care by a home health aide and/or homemaker may not be discounted or provided “at no charge” in order to qualify for CHC.

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 CHC.

Services at the CHC level of care must be billed using separately dated line items, which report the number of hours of care provided in 15-minute increments, and these increments are used in calculating the payment rate. Payment for CHC is based upon the number of 15-minute increments that are billed for 32 or more units. Rounding to the next whole hour is no longer applicable. Note: Only direct patient care during the period of crisis may be billed, and documentation of the crisis and care rendered should be noted in the Hospice medical record.

Since CHC requires a minimum of eight hours in a 24-hour period (starting at midnight and ending at 11:59 p.m. of the same day) claims with less than 32 units (15-minute increments) for the day (i.e., eight hours) will be paid at the routine care payment rate.

Billing for CHC should not reflect nursing shifts and non-direct patient increments (e.g., meal breaks, report, education of staff). CHC is not intended to be used as respite care.

Services for all hospice levels of care must be reported with a HCPCS code that identifies the location where that level of care was provided including:

If there are different or multiple locations where care has been provided, each location is to be identified with the corresponding HCPCS code as separate and distinct line items.

For services provided on or after January 1, 2007, hospices must report a HCPCS code (in FL 44) along with each level of care Revenue Code to identify the type of service location where that level of care was provided The following HCPCS codes will be used to report the type of service location for hospice services:

HCPCS Code

Descriptor

Q5001

Hospice care provided in patient's home/residence

Q5002

Hospice care provided in assisted living facility

Q5003

Hospice care provided in nursing long term care facility (LTC) or nonskilled nursing facility (NF)

Q5004

Hospice care provided in skilled nursing facility (SNF)

Q5005

Hospice care provided in inpatient hospital

Q5006

Hospice care provided in inpatient hospice facility

Q5007

Hospice care provided in long term care hospital (LTCH)

Q5008

Hospice care provided in inpatient psychiatric facility

Q5009

Hospice care provided in place not otherwise specified (NOS)

If care is rendered at multiple locations, each location is to be identified on the claim with a corresponding HCPCS code. For example, routine home care may be provided for a portion of the billing period in the patient’s residence and another portion in an assisted living facility. In this case, report one Revenue Code 651 (Routine Home Care) line with HCPCS code Q5001 and the number of days of routine home care provided in the residence and another Revenue Code 651 (Routine Home Care) line with HCPCS code Q5002 and the number of days of routine home care provided in the assisted living facility.

In submitting claims, remember that the HIPAA standard 837 Institutional claim format requires line item dates of service for all outpatient claims and Medicare classifies hospice claims as outpatient claims. For claims for services provided on or before December 31, 2006, CMS allows hospices to satisfy this requirement by placing any valid date in the Statement Covers Period dates (FL 6 on the claim). For services provided on or after January 1, 2007, service date reporting will vary between continuous home care lines as follows:

CR5245 instructs your RHHI to ensure that:

Implementation
The implementation date for this instruction is January 2, 2007.

Additional Information
For complete details, please see the official instruction issued to your intermediary regarding this change. That instruction may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1011CP.pdfExternal PDF on the CMS Web site.

Providers may also want to read the following related CRs and their related MLN Matters article:

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