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 (DVA)/Veterans Health Administration (VHA),
Public Health Service (PHS), Other Federal Agency
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This
code indicates the amount shown is that portion of a higher priority DVA/VHA,
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.