Hospice care will be reimbursed
at one of four predetermined national Medicare rates (refer to the
tables in Addendums B (urban) and C (rural) based on the type and
intensity of services furnished to the beneficiary. The labor-related
portions of each of these rates are adjusted by the wage index applicable
to the hospice program providing the care (refer to
paragraph 3.1.2,
for further explanation). A single rate is applicable for each day
of care except for continuous home care where payment is based on
the number of hours of care furnished during a 24-hour period.
3.1.1
Levels
Of Reimbursement
TRICARE will use the national
Medicare hospice rates for reimbursement of each of the following
levels of care provided by or under arrangement with an approved
hospice program:
3.1.1.1 Routine Home Care (RHC)
The hospice will be paid an RHC rate for each
day the patient is at home, under the care of the hospice, and not
receiving continuous care. Payment for RHC (i.e., revenue code 651)
will be based on the geographic location at which the service is
furnished as opposed to the location of the hospice.
3.1.1.2 Prior to
December 31, 2015, hospices will be paid a single Routine Home Care
(RHC) payment amount regardless of the volume or intensity of RHC
services provided on any given day.
Example: TRICARE
reimbursement for 30 days of RHC from November 1, 2016, through November
30, 2016, in Chicago, Illinois.
|
|
Wage Component Subject
to Index
|
x
|
Index for Chicago
|
=
|
Adjusted Wage Component
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
$111.23
|
x
|
1.0416
|
=
|
$115.86
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Adjusted Wage Component
|
+
|
Nonwage Component
|
=
|
Adjusted
Rate
|
x
|
30 days
Home Care
|
=
|
Routine Rate
|
|
|
|
|
|
|
|
|
|
|
|
|
|
$115.86
|
+
|
$50.66
|
=
|
$166.52
|
x
|
30
|
=
|
$4,995.60
|
3.1.1.3 Effective
January 1, 2016, two separate payment rates have been established
for RHC level of care depending on the timing of the day within
the patient’s episode of care. Days one through 60 will be paid
at the RHC ‘High’ Rate, while days 61 and beyond will be paid at
the RHC ‘Low’ Rate as reflected in Addendum A. These differing rates
will serve to capture varying levels of resource intensity during
the course of hospice care, as the beginning portion of the stay
is more costly than the latter segment. Patient days used in determining
which of the two RHC rates is reimbursed will be calculated in accordance
with the following provisions:
3.1.1.3.1 For hospice
patients who are discharged and readmitted to a hospice within 60
days of that discharge, a patient’s prior hospice days would continue
to follow the patient and count toward his or her patient days for
the new hospice election. The hospice days would continue to follow
the patient solely to determine whether the receiving hospice would
be paid at the day one through 60 RHC rate or day 61 and beyond
RHC rate. The patient’s episode day count is based on the total
number of days the patient has been receiving hospice care, separated
by no more than a 60-day gap in hospice care, regardless of level
of care or whether those days were billable or not. This will include
hospice days that occurred prior to January 1, 2016.
3.1.1.3.2 For hospice patients who have been discharged
from hospice care for more than 60 days, a new election to hospice
will initiate a reset of the new patient’s 60-day window, resulting
in payment at the RHC ‘High’ Rate.
Example:
|
|
• Patient elected hospice for the first time
on January 10, 2016.
|
|
|
• The patient revoked hospice on January 30,
2016.
|
|
|
• The patient re-elected hospice on February
6, 2016.
|
|
|
• The patient is discharged deceased from hospice
care on March 28, 2016.
|
|
|
|
|
Since the break
in hospice care from January 30, 2016, to February 6, 2016 was less
than 60 days, the inpatient day count continues on the second admission.
RHC provided during the first election from January 10, 2016, to
January 30, 2016, accounts for 21 days that the high RHC rate would
apply. The 60-day count continues with the second admission on February
6, 2016, and the high RHC rate would apply for an additional 39 days.
Day 61 begins the low RHC rate on March 16, 2016.
|
|
|
Multiple RHC days
are reported on a single line item on the claim. The line item date
of service represents the first date at the level of care, and the
units represent the number of days. As a result, both high and low
RHC rates may apply to a single line item. Extending the example
above, if the March claims for this patient consisted entirely of RHC
days at home, the payment line item would look like this:
|
|
|
|
|
Revenue
Code - 0651
HCPCS
- Q5001
Line Item
Date of Service - 03/01/2016
|
|
|
|
|
TRICARE Systems
would:
|
|
|
|
|
|
• Calculate the dates from 03/01 to 03/15 at
the high RHC rate;
|
|
|
• Calculate the dates from 03/16 to 03/31 at
the low RHC rate; and
|
|
|
• Sum these two amounts in the payment applied
to this line item.
|
3.1.1.4 Effective January 1, 2016, a Service Intensity
Add-on (SIA) payment may be provided for RHC days when direct patient
care is provided by a Registered Nurse (RN) or social worker during
the last seven days of the patient’s life (and the beneficiary is
discharged deceased). The SIA is a payment that may be made in addition
to the per diem rate for the RHC level of care. The SIA payment
will equal the Continuous Home Care (CHC) hourly rate multiplied
by the hours of RN nursing/social work services for at least 15
minutes and up to a total of four hours (no greater than 16 units)
that occurred on a RHC day during the last seven days of life adjusted
for geographic differences in wages.
3.1.1.4.1 It is expected
that at the End Of Life (EOL) the needs of the patient and family intensify, requiring
the specialized skills of an interdisciplinary group RN. In order
to quantify the amount of RN services subject to SIA payment, hospice claims must differentiate
between nursing services provided by an RN and nursing services
provided by a Licensed Practical Nurse (LPN).
3.1.1.4.2 The single G-code of G0154 for
“Direct skilled nursing services of a licensed nurse (LPN or RN)
in the home health or hospice setting” will be retired and replaced
with G-codes G0299 “direct skilled nursing services
of a registered nurse (RN) in the home health or hospice setting”
and G0300 “direct skilled nursing services of a Licensed Practical
Nurse (LPN) in the home health or hospice setting,” effective for
hospice dates of service on or after January 1, 2016.
Example: Billing
Period: 12/01/XXXX - 12/09/XXXX, Patient Status: 40
RHC in home, discharged deceased.
|
Revenue
Code
|
HCPCS
|
Line Item
Date of Service
|
Units
|
|
*Visits
reported prior to 12/03/XX are not included in EOL seven day SIA.
Day 1 of 7, 12/03/XX, no qualifying units
reported for the EOL SIA.Day 2 of 7, 12/04/XX, no qualifying units
reported for the EOL SIA.
Day
3 of 7, 12/05/XX, qualifying units are 4. Day 3 of the EOL SIA payment
is stored on the first applicable visit line for that date: 0561
G0155 12/05/XX UNITS 4.
Day
4 of 7, 12/06/XX, qualifying units are 3. Day 4 of the EOL SIA payment
is stored on the first applicable visit line for that date: 0551 G0299 12/06/XX
UNITS 3.
Day 5 of 7,
12/07/XX, no qualifying units reported for the EOL SIA.
Day 6 of 7, 12/08/XX, no qualifying units
reported for the EOL SIA.
Day
7 of 7, 12/09/XX, qualifying units are 10. Day 7 of the EOL SIA
payment is stored on the first applicable visit line for that date:
0551 G0299 12/09/XX UNITS 4.
|
|
0651*
|
Q5001
|
12/01/XX
|
9
|
|
0551*
|
G0154
|
12/01/XX
|
4
|
|
0571
|
G0156
|
12/02/XX
|
6
|
|
0561
|
G0155
|
12/05/XX
|
4
|
|
0571
|
G0156
|
12/05/XX
|
3
|
|
0551
|
G0299
|
12/06/XX
|
3
|
|
0571
|
G0156
|
12/06/XX
|
4
|
|
0551
|
G0299
|
12/09/XX
|
4
|
|
0561
|
G0155
|
12/09/XX
|
6
|
|
0571
|
G0156
|
12/09/XX
|
2
|
3.1.1.5
Continuous
Home Care
The hospice will be paid the continuous
home care rate when continuous home care is provided. Payment for
continuous care (i.e., revenue code 652) will be based on the geographic location
at which the service is furnished as opposed of the location of
the hospice. The continuous home care rate is divided by 24 hours
in order to arrive at an hourly rate. The following provisions are used
for payment of this level of care:
3.1.1.5.1 A minimum
of eight hours of care must be provided within a 24-hour period,
starting and ending at midnight. If less than eight hours of care
are provided within a 24-hour period, the care will be paid at the
lower RHC rate. The home health rate used will be dependent on the
timing of the day within the beneficiary’s episode of care (i.e.,
days one through 60 will be paid at the RHC high rate, while days
61 and beyond will be paid at the RHC low rate.)
3.1.1.5.2 More than
half of the continuous home care must be provided by either a RN
or LPN; i.e., a RN or LPN must provide more than one-half of the
total hours being billed for each 24-hour period.
3.1.1.5.3 Homemaker
and home health aide services may be provided to supplement the nursing
care to enable the beneficiary to remain at home.
3.1.1.5.4 For every
hour or part of an hour of continuous care furnished, the hourly
rate will be reimbursed to the hospice up to 24 hours per day. A
part of an hour will be rounded to a whole hour for each hour of
continuous care during a 24-hour period.
3.1.1.5.5 In situations where accumulative hours cannot
be associated with specific dates of service and the average number
of hours per day is equal to or greater than eight hours it can
be assumed that the eight hour minimum has been met for each of
the dates of service for continuous home care.
Example: A
hospice billed for 24 hours of continuous home care over a four
day period. Since the average number of hours was less than eight
hours per day (24 hours divided by four days equals six hours per
day), development would be required. If the number of hours had
been 32 hours or more it could have been assumed that the beneficiary
had received eight or more hours for each day of continuous home
care billed on the Centers for Medicare and Medicaid Services (CMS)
1450 UB-04.
Note: Reimbursement
can be extended for routine and continuous hospice care provided
to beneficiaries residing in a nursing home facility, that is, physician,
nurse, social worker, and home health aide visits to patients requiring
palliative care for a terminal illness. TRICARE will not pay for
the room and board charges of the nursing home.
3.1.1.6 Inpatient
Respite Care
The hospice will be paid at
the inpatient respite care rate for each day on which the beneficiary
is in an approved inpatient facility and is receiving respite care.
Payment for inpatient respite care (revenue code 655) will be based
on the geographic location of the hospice.
3.1.1.6.1 Payment
for respite care may be made for a maximum of five days at a time,
including the date of admission but not counting the date of discharge.
3.1.1.6.2 Payment
for the sixth and any subsequent days is to be made at the RHC rate. The home
health rate used will be dependent on the timing of the day within
the beneficiary’s episode of care (i.e., days one through 60 will
be paid at the RHC high rate, while days 61 and beyond will be paid at
the RHC low rate.)
Note: Respite care
can only be provided on an occasional basis and then only if it
is part of the overall treatment plan. The interdisciplinary treatment
group has the responsibility of determining the appropriateness
and frequency of respite care. Only those respite days which are
actually paid at the inpatient respite rate will be counted toward
the inpatient limitation; e.g., a respite stay of 15 days will only
be reimbursed for five days of inpatient respite care, and as such,
only those five days will be counted toward the inpatient limitation.
3.1.1.7 General Inpatient
Care
Payment at the inpatient rate will be
made when general inpatient care is provided. None of the other
fixed payment rates (i.e., RHC) will be applicable for a day on
which the patient receives general inpatient care except on the
date of discharge. Payment for general inpatient care (revenue code
656) will be based on the geographic location of the hospice.
3.1.6 Cap
on Overall Reimbursement
Each TRICARE-approved
hospice program shall be subject to
a cap on aggregate TRICARE payments from November 1 through October
31 of each year, hereafter known as “the cap period”.
3.1.6.1 Calculation/Application of Cap Amount
The contractor shall calculate and apply the
cap amount at the end of each cap period using the following guidelines:
3.1.6.1.1 The “cap amount” is calculated by multiplying
the number of TRICARE beneficiaries electing hospice care (numbers
of beneficiaries electing hospice care during the period beginning September
28 of the previous cap year through September 27 of the current
cap year) during the period by a statutory amount determined each
year by the CMS.
3.1.6.1.2 The hospice
cap is calculated in a different manner for new hospices entering
the program if the hospice has not participated in the program for
an entire cap year. In this situation, the initial cap calculations
for newly certified hospices cover a period of at least 12 months
but not more than 23 months.
3.1.6.1.3 The aggregate
cap amount will be compared with total actual TRICARE payments made during
the same cap period.
• “Total payment” refers
to payment for services furnished during the cap year beginning
November 1 and ending October 31, regardless of when payment is actually
made.
• Payments
are measured in terms of all payments made to hospices
on behalf of all TRICARE beneficiaries receiving services
during the cap year, regardless of which year the beneficiary is
counted in determining the cap (i.e., all TRICARE beneficiaries
within a particular hospice program).
• Payments made to a
hospice for an individual electing hospice care on October 5, 2014,
pertaining to services rendered in the cap year beginning November
1, 2014, and ending October 31, 2015, would be counted as payments
made during that cap year (November 1, 2014 - October 31, 2015),
even though the individual would not be counted in the calculation
of the cap for that year. The individual would, however, be counted
in the cap calculation for the following year, because the election
occurred after September 27.
3.1.6.1.4 The hospice will be responsible for reporting
the number of TRICARE beneficiaries electing hospice care during
the “cap period” to the contractor. This must be done within 30
days after the end of the “cap period”.
3.1.6.1.5 The cap
amount will be adjusted annually by the percent of increase or decrease
in the medical expenditure category of the Consumer Price Index
for all urban consumers (CPI-U).
3.1.6.1.6 The adjusted
cap amount will be obtained by DHA from the CMS prior to the end
of each cap period and provided to the contractors.
3.1.6.1.7 Payments in excess of the cap amount must be
refunded by the hospice program.
3.1.6.2 Determining
Number of Elections
The following rules must
be adhered to by the hospice in determining the number of TRICARE
beneficiaries who have elected hospice care during the period:
3.1.6.2.1 The beneficiary must not have been counted
previously in either another hospice’s cap or another reporting
year.
3.1.6.2.2 The beneficiary must file an initial election
during the period beginning September 28 of the previous cap year
through September 27 of the current cap year in order to be counted
as an electing TRICARE beneficiary during the current cap year.
3.1.6.2.3 Once a beneficiary has been included in the
calculation of a hospice cap amount, he or she may not be included
in the cap for that hospice again, even if the number of covered
days in a subsequent reporting period exceeds that of the period
where the beneficiary was included.
3.1.6.2.4 There will
be proportional application of the cap amount when a beneficiary
elects to receive hospice benefits from two or more different TRICARE-certified
hospices. A calculation must be made to determine the percentage
of the patient’s Length Of Stay (LOS) in each hospice relative to
the total length of hospice stay.
3.1.6.2.4.1 The contractor
having jurisdiction over the hospice program in which the beneficiary dies
or exhausts the hospice benefit shall be responsible for determining
the proportionate LOS for all preceding hospices.
3.1.6.2.4.2 The contractor shall also be responsible for
disseminating this information to any other contractors having jurisdiction
for hospices in which the beneficiary was previously enrolled.
Note: While it is assumed that crossing of contractor
jurisdictional areas (care in hospices located in different jurisdictional
areas) will be relatively rare, there is no question that it will
occasionally happen. Care in another jurisdictional area can only
be detected if it is reported in the admission notice or detected
upon retrospective (post payment) medical review; e.g., in the case
of a change in election, the second (receiving) hospice will use
Item 38 (CMS 1450 UB-04) of the admission notice to indicate the
transferring hospice’s complete name, address, and provider number.
The method of reporting will be left up to the individual contractor.
The information should be shared with the other contractors as soon
as possible after the demise of the beneficiary so that the other
contractors have ample time to adjust the elections used in calculating
the hospice’s cap amount. The contractor shall maintain this information
for end of the year reconciliation (figuring of cap amounts).
3.1.6.2.4.3 Each contractor shall then adjust the number
of beneficiaries reported by these hospices based on the latest
information at the time the cap is applied.
3.1.6.3 Readjustment of Cap Amount
Readjustment
may be required if information previously unavailable to the contractor
at the time the hospice cap is applied subsequently becomes available.
3.1.6.4 Apportionment of Election Between Cap Years
The following guidelines will be followed when
more than one TRICARE-certified hospice provides care to the same
individual, and the care overlaps two cap years:
3.1.6.4.1 Each contractor shall determine in which cap
year the fraction of a beneficiary should be reported.
3.1.6.4.1.1 If the beneficiary entered the hospice before
September 28, the fractional beneficiary would be included in the
current cap year.
3.1.6.4.1.2 If the
beneficiary entered the hospice after September 27, the fractional
beneficiary would be included in the following cap year.
3.1.6.4.2 Where services are rendered by two different
hospices to one TRICARE patient, and one of the hospices is not
certified by TRICARE, no proportional application is necessary.
The contractor shall count one patient and use the total cap for
the certified hospice.
3.1.6.5 Hospice Participation
at Any Time Other Than Beginning of Cap Year (November 1)
In those situations where a hospice begins
participation in TRICARE at any time other than the beginning of
a cap year (November 1), and hence has an initial cap calculation
for a period in excess of 12 months, a weighted average cap amount
is used.
Note: If Hospice A had been certified in
mid-month, a weighted average cap amount based on the number of
days falling within each cap period is used.
3.1.7 Inpatient
Limitation
Payments for inpatient hospice
care are subject to a limitation on the number of days of inpatient
care furnished to a TRICARE patient.
3.1.7.1 During
the 12-month period beginning November 1 of each year and ending
October 31, the aggregate number of inpatient days, both for general
inpatient care and respite care, may not exceed 20% of the aggregate
total number of days of hospice care provided to all TRICARE beneficiaries during
the same period.
3.1.7.2 The inpatient
limitation will be applied once each year, at the end of the hospice’s
“cap period” (November 1 - October 31).
3.1.7.3 If the
contractor (who is responsible for processing the claims) determines
that the inpatient rate should not be paid, any days for which the
hospice receives payment at a home care rate shall not be counted
as inpatient days.
Note: The accuracy
of the billing and the appropriateness of the care will be looked
at as part of the contractor medical review process. The contractor
shall only be responsible for looking for trends/patterns on a random
sampling of claims.
3.1.7.4 The inpatient
limitation shall be calculated by the contractor servicing the hospice
as follows:
3.1.7.4.1 The maximum allowable number of inpatient days
will be calculated by multiplying the total number of days of TRICARE
hospice care by 0.2.
3.1.7.4.2 If the
total number of days of inpatient care furnished to TRICARE hospice
patients is less than or equal to the maximum, no adjustment will
be necessary.
3.1.7.4.3 If the
total number of days of inpatient care exceeded the maximum allowable
number, the limitation will be determined by:
3.1.7.4.3.1 Calculating
a ratio of the maximum allowable days to the number of actual days
of inpatient care, multiplying this ratio by the total reimbursement
for inpatient care (general inpatient and inpatient respite reimbursement)
that was made.
3.1.7.4.3.2 Multiplying
excess inpatient care days by the RHC rate.
3.1.7.4.3.4 Comparing the amount in
paragraph 3.1.7.4.3.3 with
interim payments made to the hospice for inpatient care during the
“cap period”.
3.1.7.4.4 Payments
in excess of the inpatient limitation must be refunded by the hospice program.
Example: Inpatient
Limitation
Step 1: Maximum Allowable Inpatient
Days (MAIDs) are calculated by multiplying the total number of days
of TRICARE hospice care by 0.2.
|
|
Total TRICARE
Hospice Days
|
x
|
Percent Inpatient
Limitation
|
=
|
Maximum Allowable
Number of Inpatient
|
|
|
|
|
|
|
|
|
|
1,237 days
|
x
|
0.2
|
=
|
247.44
|
Step 2: Since
the total number of days (292 days) of inpatient care exceed the
maximum allowable number of inpatient days (rounded to 247 days)
the limitation will be determined by:
Step 2a: Calculating
the ratio of the maximum allowable days to the number of actual
days of inpatient care and multiplying this ratio by the total reimbursement
for inpatient care (general inpatient and inpatient respite reimbursement
that was made).
|
|
MAIDs
|
x
|
Total Inpatient Reimbursement
|
=
|
Amount
(a)
|
|
|
Actual Days
of Inpatient Care
|
|
|
|
|
|
|
|
|
|
247 days
|
x
|
$91,854.70
|
=
|
$77,699.05
|
|
|
292 days
|
Step 2b: Multiply
excess inpatient days by the RHC rate.
|
|
Excess Inpatient
Care Days
(Actual Days
- MAIDs)
|
x
|
RHC Rate for Seattle
|
=
|
Amount (b)
|
|
|
|
|
|
|
|
|
|
(292 days -
245 days) = 45 days
|
x
|
$94.02
|
=
|
$4,230.90
|
Step 2c: Add
together amounts from Steps
2a and
2b.
|
|
Amount (a)
|
+
|
Amount (b)
|
=
|
Amount (c)
|
|
|
|
|
|
|
|
|
|
$77,699.05
|
+
|
$4,230.90
|
=
|
$81,929.95
|
Step 2d: Compare
amount from Step
2c with total
TRICARE payments received and receivable for the cap period from
November 1, 1993 through October 31, 1994.
|
|
Actual TRICARE Payments
|
-
|
Amount (c) Above
of Inpatient
|
=
|
Payments in
Excess Limitation
|
|
|
|
|
|
|
|
|
|
$91,354.75
|
-
|
$81,929.95
|
=
|
$9,424.80
|
3.1.9 Hospice Reporting
Responsibilities
Unlike current Medicare
practice, under TRICARE, the hospice is still responsible for reporting
the following data to the contractor within 30 days after the end
of the cap period:
3.1.9.1 Data requirements.
3.1.9.1.1 Total number of TRICARE beneficiaries electing
hospice care during the period beginning September 28 of the previous
cap year through September 27 of the current cap year.
3.1.9.1.2 Total number of TRICARE hospice days (both
inpatient and home care).
3.1.9.1.3 Total reimbursement
received and receivable for the cap period for services furnished to
TRICARE beneficiaries, including employed physician’s services not
of an administrative and/or general supervisory nature.
3.1.9.1.4 Total reimbursement received and receivable
for general inpatient and respite care during the cap period.
3.1.9.1.5 Aggregate number of TRICARE inpatient days
for both general inpatient care and inpatient respite care during
the cap period.
3.1.9.1.6 Aggregate
number of TRICARE routine days during the cap period.
3.1.9.1.7 Aggregate total number of days of hospice care
provided to all TRICARE beneficiaries during the cap period.
3.1.9.2 Contractors shall be given discretion in designing
their own report forms taking into consideration the above data
requirements. The following is an example of an acceptable report
form:
|
|
CAP
PERIOD ENDED - October 31, ____
|
|
|
|
|
Hospice
____________________
|
|
|
|
|
Provider
Number: ___________
|
|
|
|
|
1.
|
Number
of TRICARE beneficiaries electing hospice care during the period
from 09/28/____ through 09/27/____.
|
|
|
|
|
|
|
2.
|
Total
payment received and receivable for the cap period from
11/01/____ through 10/31/____ for services furnished to TRICARE beneficiaries
during the cap period, including employed physician’s services not
of an administrative and/or general supervisory nature.
|
|
|
|
|
|
|
3.
|
Total
reimbursement received and receivable for general inpatient care
and inpatient respite care furnished to TRICARE beneficiaries for the
period from 11/01/____ through 10/31/____.
|
|
|
|
|
|
|
4.
|
Aggregate
number of TRICARE inpatient days for both general inpatient care
and inpatient respite care for the period from
11/01/____ through 10/31/____.
|
|
|
|
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a.
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Aggregate
number of TRICARE routine days for the period from 11/01/____ through
10/31/____.
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b.
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Aggregate
number of TRICARE continuous home care hours for the period 11/01/____
through 10/31/____.
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5.
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Aggregate
total number of days of hospice care provided to all TRICARE beneficiaries
for the period from 11/01/____ through
10/31/____.
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SIGNATURE
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DATE
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TITLE
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3.1.10 End of the
Year Reconciliation
The contractor shall
be responsible for calculation of the cap amount and inpatient limitation
for each TRICARE approved hospice program within its jurisdictional
area.
3.1.10.1 The information/data for calculation of the
cap amount and inpatient limitation will come directly off of the
data report form which must be submitted to the contractor within
30 days after the end of the cap period (i.e., by December 1st of
each year).
3.1.10.1.1 The contractors shall not be responsible for
validation of this information unless there is a request for reconsideration
by one of the hospice programs.
3.1.10.1.2 Adjustments
to these end of the year calculations should be minimal since the
hospice will be reporting total payments received and receivable for
the cap period.
3.1.10.1.3 Payments
for hospital based physicians (billed by the hospice program on
the CMS 1450 UB-04) will be subject to the cap amount; i.e., it
will be figured into hospice payments made during the cap period.
3.1.10.1.4 Independent attending physician or NP services
are not considered a part of the hospice benefit and are not figured
into the cap amount calculations. The provider will bill for the services
on a CMS 1500 Claim Form using appropriate Current Procedural Terminology
(CPT) codes.
3.1.10.2 The contractor
shall have 30 days (until January 1st of each year) in which to
calculate and apply the cap and inpatient amounts to each TRICARE
approved hospice within its jurisdictional area. The contractor
shall request a refund from those hospice programs found to exceed
the calculated amounts.
3.1.10.2.1 The contractor
shall be given discretion in developing its own recoupment letter/notice
as long as it includes the data elements used in establishing each
of its calculations and informs the hospice of the reconsideration
provisions allowed under
paragraph 3.1.11.
3.1.10.2.2 Refund
checks will be sent to the DHA CRM Directorate. If the hospice fails
to submit the refund, the contractor shall issue two additional
demand letters which will be sent out at appropriate intervals as
required by the TOM. Copies of the demand letters will not be sent
to the beneficiary, and providers will not be placed on offset to
collect overpayments. If the providers do not voluntarily refund
the indebtedness in full, or do not enter into an installment repayment
agreement, recoupment cases will be transferred to DHA in compliance
with the TOM.
3.1.12 Billing Procedures
Completion of the CMS 1450 UB-04 for hospice
care. The following is information needed for completion of those
items required for the billing of hospice care. Items not listed
need not be completed unless otherwise required in double coverage
situations.
3.1.12.1 Item 1 - Provider Name, Address, and Telephone
Number Required
Enter name, city, state,
and zip code. The post office box number or street name and number
may be included. The state may be abbreviated using standard post
office abbreviations.
3.1.12.2 Item 4 -
Type of Bill (TOB) Required
This three digit
code gives three specific pieces of information. The first digit
identifies the type of facility. The second digit classifies the
type of care. The third digit indicates the sequence of this bill
in this particular episode of care (referred to as a “frequency”
code).
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Code
Structure
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first Digit - Type of Facility
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08 - Special
(Hospice)
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second Digit - Classification
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1 - Hospice
(Nonhospital-Based)
2
- Hospice (Hospital-Based)
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third Digit - Frequency Definition
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1
- Admit Through Discharge Claim
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Use this code
for a bill encompassing an entire course of hospice treatment for which
you expect reimbursement; i.e., no further bills will be submitted
for this patient.
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2
- Interim - First Claim
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Use this code
for the first of an expected series of payment bills for a hospice course
of treatment.
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3
- Interim - Continuing Claim
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Use this code
when a payment bill for a hospice course of treatment has been submitted
and further bills are expected to be submitted.
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4
- Interim - Last Claim
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Use this code
for a payment bill which is the last of a series for a hospice course
of treatment. The “Through” date of this bill (Item 6) is the discharge
date or date of death.
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7
- Replacement of Prior Claim
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Use this code
to correct (other than late charges) a previously submitted bill.
This is the code applied to the corrected or “new” code.
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8
- Void/Cancel of a Prior Claim
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This code indicates
this bill is an exact duplicate of an incorrect bill previously submitted.
Submit a code “7” (Replacement of Prior Claim) to show the corrected information.
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3.1.12.3 Item 5 -
Federal Tax Number
Enter Tax Identification
Number (TIN) or Employer Identification Number (EIN) and the sub-ID
assigned by the contractor.
3.1.12.4 Item 6 -
Statement Covers Period (From-Through) Required
Show
the beginning and ending dates of the period covered by this bill
in numeric fields (MM-DD-YY). Do not show days before the patient’s
eligibility began. Since the 12-month hospice “cap period” ends
each year on October 31, hospice services for October and November
cannot be submitted on the same bill. Use October 31 as a cutoff
date. Submit separate bills for October and November.
Note: If the hospice bills for services that cross the
cap period split the bill and process the October portions through
the cap period cutoff date of October 31. Return the November portion
of the bill uncontrolled.
3.1.12.5 Item 12 -
Patient’s Name Required
Show the patient’s
name with the surname first, first name, and middle initial, if
any.
3.1.12.6 Item 13 - Patient’s Address Required
Show the patient’s full mailing address including
street name and number or RFD, city, state, and zip code.
3.1.12.7 Item 14 - Patient’s Birthdate Required
Show the month, day, and year of birth numerically
as MM-DD-YY. If the date of birth cannot be obtained after a reasonable
effort, leave this field blank.
3.1.12.8 Item 15 -
Patient’s Sex Required
Show an “M” for male
or an “F” for female.
3.1.12.9 Item 17 -
Admission Date Required
Enter the admission
date, which must be the same date as the effective date of the hospice election,
or change of election. The date of admission may not precede the
physician’s certification by more than two calendar days. Show the
month, day, and year numerically as MM-DD-YY.
3.1.12.10 Item 22 - Patient Status Required
This code indicates the patient’s status as
of the “Through” date of the billing period (Item 6).
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Code
Structure
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01
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Discharged (left
this hospice)
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30
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Still patient
(remains a patient)
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40
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Died at home
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41
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Died in a medical
facility, such as a hospital, SNF, or freestanding hospice
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42
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Place of death
unknown
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3.1.12.11 Item 32,
33, 34, and 35 - Occurrence Codes and Dates
Show
code(s) and associated date(s) defining specific event(s) relating
to this billing period. Event codes are two numeric digits and dates
are six numeric digits (MM-DD-YY). If there are more occurrences
than there are spaces on the form, use Item 36 (occurrence span)
or Item 84 (remarks) to record additional occurrences and dates.
Use the following occurrence codes where appropriate:
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Code
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Title
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Definition
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24
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Date
Insurance Denied
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This code indicates
the date you received the denial of coverage from an insurer other
than TRICARE.
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42
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Termination
of Hospice Care
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The date the
patient’s hospice care ends. Care may be terminated by a change
in the hospice election to another hospice, a revocation of the
hospice election, or death.
Show
the termination code 42 in Item 32.
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3.1.12.12 Item 38 -
Transferring Hospice ID Required
3.1.12.12.1 Only when
the admission is for a patient who has changed an election from
one hospice to another.
3.1.12.12.2 When a
receiving (second) hospice submits an admission notice involving
a patient who changed the hospice election, this item reflects the
transferring hospice’s complete name, address, and provider number.
This information alerts the contractor that the admission continues
a current hospice benefit period rather than begins a new one.
3.1.12.13 Items 39, 40, and 41 - Value Codes and Amounts
The only value codes that apply to hospice
benefits are those that indicate TRICARE payment is secondary to
another payer. Enter the appropriate code(s) and related dollar
amount(s) where the primary payer is other than TRICARE, and where
the primary payer has made payment at the time of billing TRICARE.
If the primary payer has denied payment, indicate this with zeros
in the value amount. Enter the date of the denial and occurrence
code 24 in the appropriate field. The value codes are two numeric
digits, and each value allows up to eight numeric digits (000000.00).
If more than one value code is shown for a billing period, show
codes in ascending numeric sequence. There are four lines of data:
a, b, c, and d. Use Items 39a through 41a before Items 39b through
41b (i.e., the first line is used up before the second line is used).
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Code
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Title
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Definition
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12
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Working
Age/Beneficiary/Spouse with Employer Group Health Plan (EGHP)
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This
code indicates the amount shown in that portion of a higher priority EGHP
payment that you are applying to covered TRICARE charges on this
bill.
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13
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End
Stage Renal Disease (ESRD) in the 12-month coordination period with
an EGHP
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This
code indicates the amount shown is that portion of a higher priority EGHP
payment made on behalf of an ESRD beneficiary that you are applying to
covered TRICARE charges on the bill.
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14
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Automobile,
No-Fault or Any Liability Insurance
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This
code indicates the amount shown is that portion of a higher priority automobile,
no-fault or liability insurance payment made on behalf of a TRICARE
beneficiary you are applying to covered TRICARE charges on this
bill.
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15
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Worker’s
Compensation (WC) including Black Lung (BL)
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This
code indicates the amount shown is that portion of a higher priority
WC insurance payment made on behalf of a TRICARE beneficiary you
are applying to covered TRICARE charges on this bill.
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16
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Department
of Veterans Affairs (VA), Public Health Service (PHS), Other Federal
Agency
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This
code indicates the amount shown is that portion of a higher priority
VA, PHS, or other Federal Agency’s payment made on behalf of a TRICARE beneficiary
that you are applying to covered TRICARE charges on this bill.
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3.1.12.14 Item 42 -
Revenue Code Required
3.1.12.14.1 Assign
a revenue code for each reimbursement rate. Enter the appropriate
three digit numeric revenue code on the adjacent line in column
42 to explain each charge in column 43.
Note: Use revenue code 657 to identify the charges for
services furnished to patients by physicians employed by, or receiving
compensation from the hospice. In conjunction with revenue code
657, enter the appropriate physician CPT procedure codes in Item
44. CPT procedure codes are required in order that the contractor
may make allowable charge determinations when reimbursing hospice
physicians.
3.1.12.14.2 Use these
revenue codes to bill TRICARE.
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Code
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Description
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Standard
Abbreviation
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651
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Routine
Home Care
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RTN
Home
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652
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Continuous
Home Care
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CTNS
Home (a minimum of eight hours, not necessarily consecutive, in
a 24-hour period is required. Less than eight hours is routine home
care for reimbursement purposes. A portion of an hour is one hour).
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655
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Inpatient
Respite Care
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IP
Respite
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656
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General
Inpatient Care
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GNL
IP
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657
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Physician
Services
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PHY
Ser (must be accompanied by a physician CPT procedure code)
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3.1.12.15 Item 46 -
Units of Service Required
Enter the number
of units for each type of service on the line adjacent to the revenue
code and description. Units are measured in days for codes 651,
655, and 656, in hours for code 652, and in procedures for code
657.
3.1.12.16 Item 47 - Total Charges Required
Enter the total charges for the billing period
by revenue code (column 42) on the adjacent line in column 47. The
last revenue code entered in column 42 represents the grand total
of all charges billed. The total is in column 47 on the adjacent
line. Each line allows up to eight numeric digits (000000.00).
3.1.12.17 Item 50A, B, C - Payer Identification Required
If TRICARE is the only insurer other
than Medicaid and TRICARE Supplemental Plans, TRICARE is the primary
payer. Enter the correct contractor in line 50A. If there are other
insurers besides Medicaid and TRICARE supplemental plans, TRICARE
is not the primary payer. Enter the name of the group(s) or plan(s)
in line 50A or 50A and 50B. Enter the correct contractor in line
50B or 50C.
3.1.12.18 Item 58A,
B, C - Insured’s Name Required
If the primary
payer(s) is other than TRICARE, enter the name of person(s) carrying other insurance
in 58A or 58A and 58B. Enter the sponsor’s name in line 58B or 58C
if TRICARE patient as recorded on ID card. If TRICARE is primary,
enter the sponsor’s name as recorded on the ID card, in line 58A.
3.1.12.19 Item 60A, B, C - Certificate/Social Security
Number (SSN)/Health Insurance Claim/Identification Number
If primary payer(s) is other than TRICARE,
enter the unique ID number assigned by the primary payer to the
person(s) carrying other insurance in line 60A or 60A & 60B.
Enter the sponsor’s SSN in line 60B or 60C if TRICARE patient; or
enter the North Atlantic Treaty Organization (NATO)/Partnership
for Peace (PfP) in line 60B or 60C if a NATO/PfP beneficiary.
3.1.12.20 Item 67 - Principal Diagnosis Code Required
For services provided before the mandated date,
as directed by Health and Human Services (HHS), for International
Classification of Diseases, 10th Revision (ICD-10) implementation,
show the full International Classification of Diseases, 9th Revision,
Clinical Modification (ICD-9-CM) diagnosis code. For services provided
on or after the mandated date, as directed by HHS, for ICD-10 implementation, show
the full ICD-10-CM diagnosis code. The principal diagnosis is defined
as the condition established after study to be chiefly responsible
for occasioning the patient’s admission.
3.1.12.21 Item 82 - Attending Physician ID Required
Enter the name, number and address of the licensed
physician normally expected to certify and recertify the medical
necessity of the services rendered and/or who has primary responsibility
for the patient’s medical care and treatment. Use Item 84 “Remarks”
for additional space for recording this information.
3.1.12.22 Item 78 - Other Physician ID Required
Enter the word “employee” or “nonemployee”
to describe the relationship that the patient’s attending physician
has with the hospice program.
3.1.12.23 Item 80 -
Remarks
Enter any remarks needed to provide
information not shown elsewhere on the bill but which are necessary
for proper payment.
3.1.12.24 Items 85
and 86 - Provider Representative Signature and Date
Deleted from UB-04, see FL 45, line 23. A hospice
representative makes sure that the required physician’s certification
and a signed election statement are in the records before submitting the
CMS 1450 UB-04.
3.1.13 Special Processing
and Reporting Requirements
3.1.13.1 The various
levels of hospice care will be considered institutional care for
payment and reporting purposes. The special rate code “P” (TRICARE
Systems Manual (TSM),
Chapter 2, Section 2.8) will be designated
for the four levels of hospice care.
3.1.13.2 The conventional
coding for hospice care on the CMS 1450 UB-04, Item 4, is a four
digit numerical code designating the TOB required.
3.1.13.2.1 For institutional
reporting purposes the first two digits will be converted to the appropriate
TYPE OF INSTITUTION code provided in the TSM,
Chapter 2, Addendum D. Code 81 will be converted
to 78 (non-hospital based hospice) and code 82 will be converted
to 79 (hospital-based hospice).
3.1.13.2.2 The third
digit will be reported on a separate institutional reporting field
(FREQUENCY CODE), TSM,
Chapter 2, Section 2.5.
3.1.13.3 Type of institution codes 78 and 79 along with
the special processing code # (TSM,
Chapter 2, Addendum D) will allow hospice
institutional claims to by-pass all cost-sharing edits.
3.1.13.4 The revenue code 0657 will be used to identify
the charges for services furnished to patients by physicians employed
by, or receiving compensation from the hospice.
3.1.13.4.1 Physician
procedure codes (CPT procedure codes) will be entered in Item 44
of the CMS 1450 UB-04 to the right of the revenue code 0657 (Item
42). The CPT procedure codes are required in order that the contractor
shall make allowable charge (CMAC) determinations when reimbursing hospice
physicians.
3.1.13.4.2 Hospice
professional services will be paid at 100% of the allowed charge.
3.1.13.4.3 Place of service code 34 (TSM,
Chapter 2, Section 2.7) along with the special
processing code number will allow hospice non-institutional claims
(hospice physician charges) to by-pass all cost-sharing edits and
to be paid at 100% of the allowed charge (CMAC).
3.1.13.5 Institutional services (i.e., routine home
care-651, continuous home care-652, inpatient respite care-655,
and general inpatient care-656) will be reported on an institutional
claim format while hospice physician services (revenue code 657
and accompanying CPT procedure codes) will be reported on a non-institutional
claim format. The claim will be split for reporting purposes.
3.1.13.6 Patient care services rendered by an independent
attending physician or NP (physician or NP who is not considered
employed by, or under contract with the hospice) are not considered
a part of the hospice benefit, and as such, will be billed in his/her
own right.
3.1.13.6.1 Independent attending physician or NP services
will be subject to standard TRICARE allowable charge methodology
(i.e., subject to standard deductible and cost-sharing provisions).
3.1.14 Billing for
Covered TRICARE Services Unrelated to Hospice Care
3.1.14.1 Any covered
TRICARE services not related to the treatment of the terminal condition
for which hospice care was elected, which are provided during a
hospice period, are billed to the contractor for non-hospice reimbursement.
3.1.14.2 Non-hospice services are billed by the provider
in accordance with existing claims processing procedures under the
TRICARE program.
3.1.14.3 The contractor
shall identify and review all inpatient claims for beneficiaries
who have elected hospice care to make sure that for:
• Nonrelated hospital
admissions, nonhospice TRICARE coverage is provided to a beneficiary
only when hospitalization was for a condition not related to his
or her terminal illness; and
• Conditions related
to a beneficiary’s terminal illness, the claims were denied.
Note: Many illnesses may occur when an individual is
terminally ill which are brought on by the underlying condition
of the patient. For example, it is not unusual for a terminally
ill patient to develop pneumonia or some other illness as a result
of his or her weakened condition. Similarly, the setting of bones
after fractures occur in a bone cancer patient would be treatment
of a related condition. The treatment of these related conditions
is part of the overall hospice benefit, and as such, shall
not be billed as a non-hospice TRICARE claim, except
for services of an attending physician who is not employed by, or
under contract with, the hospice program.
3.1.14.4 Effective December 12, 2017,
the contractor shall no longer be responsible for reviewing all inpatient
claims for beneficiaries under the age of 21 electing hospice care
since coverage and reimbursement is being extended for treatment
related to the terminal illness under concurrent care. These Basic
Program services shall be reimbursed in addition to the non-hospice
reimbursement currently available for direct patient care services
rendered by either an independent attending physician or physician
employed by or under contract with a hospice and for treatment of
non-related conditions.