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/____.
|
|
|
|
|
|
|
a.
|
Aggregate number
of TRICARE routine days for the period from 11/01/____ through 10/31/____.
|
|
|
|
|
|
|
b.
|
Aggregate number
of TRICARE continuous home care hours for the period 11/01/____
through 10/31/____.
|
|
|
|
|
|
|
5.
|
Aggregate total
number of days of hospice care provided to all TRICARE beneficiaries
for the period from 11/01/____ through
10/31/____.
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
SIGNATURE
|
|
|
DATE
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
TITLE
|
|
|
|
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).
|
Code Structure
|
|
first Digit - Type of Facility
|
|
08 - Special
(Hospice)
|
|
|
second Digit - Classification
|
|
1 - Hospice
(Nonhospital-Based)
2 - Hospice
(Hospital-Based)
|
|
|
third Digit - Frequency Definition
|
|
1 - Admit Through
Discharge Claim
|
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.
|
|
2 - Interim
- First Claim
|
Use this code
for the first of an expected series of payment bills for a hospice course
of treatment.
|
|
3 - Interim
- Continuing Claim
|
Use this code
when a payment bill for a hospice course of treatment has been submitted
and further bills are expected to be submitted.
|
|
4 - Interim
- Last Claim
|
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.
|
|
7 - Replacement
of Prior Claim
|
Use this code
to correct (other than late charges) a previously submitted bill.
This is the code applied to the corrected or “new” code.
|
|
8 - Void/Cancel
of a Prior Claim
|
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.
|
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).
|
Code Structure
|
|
01
|
Discharged (left
this hospice)
|
|
30
|
Still patient
(remains a patient)
|
|
40
|
Died at home
|
|
41
|
Died in a medical
facility, such as a hospital, SNF, or freestanding hospice
|
|
42
|
Place of death
unknown
|
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:
|
Code
|
Title
|
Definition
|
|
24
|
Date Insurance
Denied
|
This code indicates
the date you received the denial of coverage from an insurer other
than TRICARE.
|
|
42
|
Termination
of Hospice Care
|
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.
|
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).
|
Code
|
Title
|
Definition
|
|
12
|
Working Age/Beneficiary/Spouse with
Employer Group Health Plan (EGHP)
|
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.
|
|
13
|
End Stage Renal
Disease (ESRD) in the 12-month coordination period with an EGHP
|
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.
|
|
14
|
Automobile,
No-Fault or Any Liability Insurance
|
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.
|
|
15
|
Worker’s Compensation
(WC) including Black Lung (BL)
|
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.
|
|
16
|
Department of
Veterans Affairs (DVA)/Veterans Health Administration (VHA), Public Health
Service (PHS), Other Federal Agency
|
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.
|
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.
|
Code
|
Description
|
Standard Abbreviation
|
|
651
|
Routine Home
Care
|
RTN Home
|
|
652
|
Continuous Home
Care
|
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).
|
|
655
|
Inpatient Respite
Care
|
IP Respite
|
|
656
|
General Inpatient
Care
|
GNL IP
|
|
657
|
Physician Services
|
PHY Ser (must
be accompanied by a physician CPT procedure code)
|
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.