Hospice
care will be reimbursed at one of four predetermined national Medicare
rates (refer to
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 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 calendar 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 calendar 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
calendar 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 calendar 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 calendar 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 an RN or LPN; i.e., an 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 calendar days
will only be reimbursed for five calendar days of inpatient respite
care, and as such, only those five calendar 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 calendar 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.
3.1.6.2.4.3 The contractor shall maintain
information for end of the year reconciliation (figuring of cap amounts).
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.
3.1.6.2.4.4 The 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 The 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 The contractor shall count
one patient and use the total cap for the certified hospice 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).
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.
3.1.7.4 The contractor shall only be
responsible for looking for trends/patterns on a random sampling
of claims. The accuracy of the billing and the appropriateness of
the care will be looked at as part of the contractor medical review
process.
3.1.7.5 The contractor servicing the
hospice shall calculate the inpatient limitation by as follows:
3.1.7.5.1 The maximum allowable number
of inpatient days will be calculated by multiplying the total number
of days of TRICARE hospice care by 0.2.
3.1.7.5.2 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.
3.1.7.5.3 If the total number of days
of inpatient care exceeded the maximum allowable number, the limitation
will be determined by:
3.1.7.5.3.1 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.
3.1.7.5.3.2 Multiplying
excess inpatient care days by the RHC rate.
3.1.7.5.3.4 Comparing the amount in
paragraph 3.1.7.5.3.3 with interim payments
made to the hospice for inpatient care during the “cap period”.
3.1.7.5.4 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 calendar 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 The contractor will be given
discretion in designing its 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/____.
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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 contractor 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
calendar 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.
3.1.10.2.1 The contractor shall request
a refund from those hospice programs found to exceed the calculated amounts.
3.1.10.2.2 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.
3.1.10.2.3 The contractor shall issue
two additional demand letters which will be sent out at appropriate intervals
as required by the TOM if the hospice fails to submit the refund.
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. Refund checks
will be sent to the DHA CRM.
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 codes in Item 44. CPT 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 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 The contractor shall make allowable
charge (CMAC) determinations using required CPT codes when reimbursing
hospice physicians. Physician procedure codes (CPT codes) will be
entered in Item 44 of the CMS 1450 UB-04 to the right of the Revenue
code 0657 (Item 42).
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 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 or 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 The contractor shall, effective
December 12, 2017, 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.