Medlearn
Matters…Information for Medicare
Providers
(Issued by the Centers for
Medicare & Medicaid
Services)
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MMA-Hospice
Pre-Election Evaluation and Counseling
Services
Provider Types Affected
Hospices, their medical directors and physician
employees
Provider Action Needed
Impact to You
Section 512 of the Medicare Prescription Drug Improvement
and Modernization Act of 2003 (MMA) provides for a
one-time payment to a hospice for pre-election evaluation
and counseling services furnished by a physician who is
either a medical director or an employee
of the hospice agency. HCPCS code G0337
will be used for these services and the payments for
these services will not be included in the hospice
payment cap.
What You Need to Know
Effective
with services provided on or after January 1, 2005,
Medicare systems will pay for hospice pre-election
evaluation and counseling services furnished by the
hospice medical director or physician employee no
more than one time only per beneficiary. Payment
will be made on behalf of a beneficiary who is terminally
ill (prognosis of six months or less if the disease runs
its normal course), has not made a hospice election, and
has not previously received hospice pre-election
evaluation and counseling services.
What You Need to Do
To ensure
accurate claims processing, please review the information
included here and stay current with instructions for
hospice pre-election evaluation and counseling services.
(The FY 2005 national payment amount for this service
will be $54.57; future changes in the rate will be
identified in the Physician Fee Schedules.)
Background
Effective January 1,
2005, Section 512 of the MMA amends Section
1812(a)(1)(5), 1814(i) and 1816(dd) of the Act to provide
for a one-time payment to a hospice for evaluation and
counseling services furnished by a physician who is
either the medical director or an employee of the hospice
agency.
To be eligible to receive this service, a beneficiary
must:
- Be determined to have terminal illness (which is
defined as having a prognosis of six months or less if
the disease or illness runs its normal course);
- Not have made a hospice election; and
- Not have previously received the pre-election
evaluation and counseling services.
Services under this benefit are comprised of:
- Evaluation of the patient’s need for pain and
symptom management;
- Counseling regarding hospice and other care
options; and may include
- Advice regarding advanced care planning.
The above noted services are currently available
through other Medicare benefits. Therefore, this service
may not be reasonable and necessary for all individuals.
However, if a beneficiary or the beneficiary’s
physician deem it necessary to seek the expertise of a
hospice medical director or physician employee, this
benefit is available to assure that a beneficiary’s
end-of-life options for care and pain management are
addressed.
Please note that the evaluation and counseling service
may not be initiated by the hospice (that is, the entity
receiving payment for the service).
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Payments by hospice agencies to physicians or
others in a position to refer patients for
services furnished under this provision may
implicate the Federal anti-kickback statute.
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If the beneficiary’s physician is also the
medical director of a hospice, employed by a hospice,
or possesses expertise in the provision
of palliative or hospice care, that physician:
- Already possesses the expertise necessary to
furnish end-of-life services; and
- Will have received payment for these services
through the use of evaluation and management (E&M)
codes.
Documentation
Appropriate documentation guidelines should be followed
whether the beneficiary or the
beneficiary’s physician initiates the request for
the evaluation and counseling service.
If the beneficiary’s physician
initiates the request, which must be in writing,
then:
- Determination of the terminal diagnosis should be
included; however,
- Certification of the terminal diagnosis is not
required, since this provision is not a prerequisite or
part of the hospice benefit.
The hospice medical director or physician employee
would be expected to provide a written note on the
patient’s medical chart and maintain a written
record of this service.
If the beneficiary initiates the
request for the service, the hospice medical director or
physician employee should:
- Maintain a written record of the service; and
- With the beneficiary’s permission,
communicate with the beneficiary’s physician to
the extent necessary to ensure continuity of care.
Payment
Section 512 of
the MMA specifies that the payment will be made to the
hospice for services provided by the hospice medical
director or physician employed by the hospice. The
provision of these services may not be delegated to any
other hospice personnel (such as nurse practitioners,
registered nurses, social workers, or others) and may not
be furnished by a physician under contract with the
hospice.
Payment to the hospice agency for the provision of
this evaluation and counseling service is made using
HCPCS code G0337. The national payment amount for this
service for FY 2005 will be $54.57.
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Code G0337 will be paid only when billed by
the hospice agency to its Medicare intermediary.
Claim line items with G0337 submitted to a
Medicare carrier will be denied. The hospice
should submit such claims to its intermediary
using type of bill 81x or 82x with the G0337 code
and a revenue code of 0657 as the
only revenue code on the
claim.
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Future changes in the rate will be identified in the
Physician Fee Schedule.
The payment for these services is not included in the
hospice payment cap, as the Evaluation and Counseling
provision is not a service within the hospice
benefit.
Additional Information
The
official instructions issued to the intermediary
regarding this change can be found at:
http://www.cms.hhs.gov/Transmittals/
On the above page, scroll down while referring to the
CR NUM column on the right to find the links for CR3585.
Click on the links to open and view the files for those
CRs.
The two issuances of CR3585 include the actual revised
sections of the Medicare Claims Processing and Medicare
Benefit Policy Manuals resulting from this change.
If you have questions regarding this issue, please
contact your fiscal intermediary at their toll free
number, which may be found at: http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf
Disclaimer
Medlearn Matters articles are
prepared as a service to the public and are not intended
to grant rights or impose obligations. Medlearn Matters
articles 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.
For additional information, visit the Medlearn Matters
Web page at www.cms.hhs.gov/medlearn/matters.
Related Change Request (CR) #:
3585
Medlearn Matters Number: MM3585
Related CR Release Date: December 3,
2004
Related CR Transmittal #: 28 and 386
Effective Date: January 1,
2005
Implementation Date: January 3, 2005
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