What is hospice care and length of the stay

Hospice

The term “hospice care” means the following items and services provided to a terminally ill individual by, or by others under arrangements made by, a hospice program under a written plan (for providing such care to such individual) established and periodically reviewed by the individual's attending physician and by the medical director (and by the interdisciplinary group described in paragraph (2)(B)) of the program—

•    (A) nursing care provided by or under the supervision of a registered professional nurse,

•    (B) physical or occupational therapy, or speech-language pathology services,

•    (C) medical social services under the direction of a physician,

•    (D)(i) services of a home health aide who has successfully completed a training program approved by the Secretary and o    (ii) homemaker services,

•    (E) medical supplies (including drugs and biologicals) and the use of medical appliances, while under such a plan,

•    (F) physicians' services,

•    (G) short-term inpatient care (including both respite care and procedures necessary for pain control and acute and chronic symptom management) in an inpatient facility meeting such conditions as the Secretary determines to be appropriate to provide such care, but such respite care may be provided only on an intermittent, nonroutine, and occasional basis and may not be provided consecutively over longer than five days,

•    (H) counseling (including dietary counseling) with respect to care of the terminally ill individual and adjustment to his death, and

•    (I) any other item or service which is specified in the plan and for which payment may otherwise be made under this title.

The care and services described in subparagraphs (A) and (D) may be provided on a 24-hour, continuous basis only during periods of crisis (meeting criteria established by the Secretary) and only as necessary to maintain the terminally ill individual at home.

Hospice CPT Coding FAQ

How do I bill for hospice services? 

The following is an excerpt from the “Part B Answer Book” CD-ROM. 

Hospice Care: Overview 

If  one  of  your  patients  has  a  terminal  illness,  with  about  six  months  or  less  to  live,  your  patient  can  choose  either  standard  Medicare  coverage  or  hospice  care.  When  someone  chooses  hospice  benefits, he/she may continue to rely on a private doctor and at the same time make use of the hospice physician. 

As of Aug. 5, 1997, hospice care is available for two 90-day periods and an unlimited number of 60-day periods during the hospice patient’s lifetime. 

Hospice services (including those of the hospice physician) are billed under Part A to the intermediary, which pays 100% of Medicare’s approved charges. Services for an attending physician not connected to the hospice are billed to the carrier. Such services by an attending physician should be coded with the GV  modifier

What Medicare Will Pay For 

Medicare hospice benefits pay for treatment designed to keep  your patient as comfortable as possible. Attempts  to  cure  the  condition  that  brings  your  patient  to  the  hospice  don’t  fall  under  this  particular benefit. (The carrier’s medical staff makes the decision about what is and isn’t palliative care). However, you can bill Medicare for curative treatment that isn’t part of the terminal condition, just as you ordinarily would, whether you’re the patient’s private doctor or you work for the hospice. 

Once hospice coverage is elected, the patient isn’t eligible for Medicare Part B services related to the treatment and management of his terminal illness. One big exception is that professional services of an attending physician may be billed under Part B. To qualify as an attending physician, the patient must identify at the time he elects hospice coverage, the physician (doctor of medicine or osteopathy) who has the most significant role in his/her medical care. The attending physician doesn’t have to be employed by the hospice, and the patient still may be treated by hospice-employed physician. 

Two Paths for Reimbursement 

You can bill the carrier for treatment and management of a hospice patient’s terminal illness and get paid 80% of the Medicare fee schedule amount (plus the co-insurance and deductible) – as long as you are the attending physician, and you don’t furnish the services under a payment arrangement with the hospice. 

Member Enrolled in hospice ? Does Medicare HMO covers the service?

What is Hospice? 

Hospice is a program of care and support for people who are terminally ill.  It is available as a benefit under Medicare Hospital Insurance (Part A).  The focus of hospice is on care, not treatment or curing an illness.  Emphasis  is  placed  on  helping  people  who  are  terminally  ill  live  comfortably  by  providing comfort and relief from pain. Some important facts about hospice are: 

** A  specially  trained  team  of  professionals  and  caregivers  provide  care  for  the  “whole  person”, including his or her physical, emotional, social and spiritual needs. 

** Services may include physical care, counseling, drugs, equipment, and supplies for terminal illness and related condition(s). 

** Care is generally provided in the home. 

** Hospice isn’t only for people with cancer. 

** Family caregivers can get support. 

When all the requirements are met, the Medicare hospice benefit includes: 

** Physician and nursing services 

** Medical equipment and supplies 

** Outpatient drugs or biological for pain relief and symptom management 

** Hospice aide and homemaker services 

** Physical, occupational and speech-language pathology therapy services 

** Short term inpatient and respite care 

** Social worker services 

** Grief and loss counseling for the member and his or her family 

When  a  member/patient  enrolled  in  hospice  receives  care  from  your  practice  or  facility,  it  is  very important that all of the care be coordinated with their hospice physician. Once a Member is enrolled in hospice, CarePlus Health Plans, Inc. (CarePlus) is not financially responsible for any services covered by Medicare regardless of whether the care is related to the hospice diagnosis or not, as long as the service provided is a Medicare covered benefit. CarePlus enrolls Hospice members into a new group effective the 1st of the month, following election of hospice, and removes them from the group at the end of the month, if the Member terminates or revokes the hospice benefit.  The Plan will continue to assist in coordination of the member’s care to the best of its ability, however, the payment process to providers changes. 

Tricare hospice coverage and benefit period

Hospice Care

TRICARE has adopted most of the provisions currently set out in Medicare’s hospice coverage benefit guidelines, reimbursement methodologies, and certification criteria for participation in the hospice program. The hospice benefit is designed to provide palliative care to individuals with prognoses of less than six months to live if the terminal illness runs its normal course. This type

of care emphasizes supportive services, such as pain control and home care, rather than cure- oriented treatment.

All TRICARE beneficiaries are eligible for the hospice benefit.

Hospice care must be provided by a Medicare-certified hospice agency. If the  hospice provider is not currently TRICARE-certified, it may download the Institutional Provider File Application form at www.triwest.com/provider in the “Find a Form” section.

HOSPICE CLAIMS SUBMITTED DIRECTLY TO MCR INCORRECTLY

DESCRIPTION OF THE ISSUE

Previously we had billed Hospice covered patient claims to Medicare with GW modifier to get quicker payments. Balance of 20% coinsurance was billed towards patients. Client raised an issue to file the claims to the concerned Hospice care itself instead of billing Medicare.

CONCEPT

Whenever we find patients with Hospice coverage for a particular service date, we must check with Hospice whether the patient was in Hospice for the specific DOS, if yes we must bill that concerned Hospice care and not Medicare, if not we could bill Medicare with GW modifier (which indicates the claim not related to Hospice).