Hospice
care
is reimbursed at one of four predetermined
national Medicare rates (refer to the tables in Addendums B (urban)
and C (rural) based
upon 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
(CHC) where
payment is based
upon the number of
hours of care furnished during a 24-hour period.
3.1.1
Levels
Of Reimbursement
The TRICARE Program uses 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 is 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) is based upon 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
are paid
at the RHC ‘High’ Rate, while days 61 and beyond
are paid
at the RHC ‘Low’ Rate as reflected in Addendum A. These differing
rates
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
are calculated
in accordance with the following provisions:
3.1.1.3.1 When a hospice patient
is discharged and readmitted to a hospice within
60 days of that discharge, the patient’s
prior hospice days continue to follow
the patient and count toward the beneficiary’s patient
days for the new hospice election. The hospice days continue
to follow the patient solely to determine whether the receiving
hospice is paid at the day one through
60 RHC rate or day 61 and beyond RHC rate. The patient’s episode
day count is based upon 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 includes hospice
days that occurred prior to January 1, 2016.
3.1.1.3.2 For hospice patients discharged
from hospice care for more than 60 days, a new election to hospice
initiates 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 applies.
The 60-day count continues with the second admission on February
6, 2016, and the high RHC rate applies 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 looks like
this:
|
|
|
|
|
Revenue Code - 0651
Healthcare Common
Procedure Coding System (HCPCS) -
Q5001
Line Item Date of Service -
03/01/2016
|
|
|
|
|
TRICARE Systems:
|
|
|
|
|
|
• 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
equal
s the
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. To
quantify the amount of RN services subject to SIA payment, hospice
claims shall differentiate between
nursing services provided by an RN and nursing services provided
by a Licensed Practical Nurse (LPN).
3.1.1.4.2 Effective for
hospice dates of service on or after January 1, 2016, 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” is 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.”
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 is paid
the CHC rate when CHC is
provided. Payment for continuous care (i.e., revenue code 652) is based upon the
geographic location at which the service is furnished as opposed to the
location of the hospice. Divide the
continuous home care rate by 24 hours to
arrive at an hourly rate. Use the following
provisions for payment of this level
of care:
3.1.1.5.1 A minimum of eight hours of
care is 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 is paid
at the lower RHC rate. The home health rate used is dependent
on the timing of the day within the beneficiary’s episode of care
(i.e., days one through 60 are paid
at the RHC high rate, while days 61 and beyond are paid
at the RHC low rate.)
3.1.1.5.2 More than half of the continuous
home care is provided by either a RN
or LPN, (i.e., an RN
or LPN provides 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 is reimbursed
to the hospice up to 24 hours per day. A part of an hour is 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
are not associated with specific
dates of service and the average number of hours per day is equal
to or greater than eight hours
then 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 is required.
If the number of hours had been 32 hours or more,
then the beneficiary had received eight or more hours
for each day of CHC billed on the Centers
for Medicare and Medicaid Services (CMS) 1450 UB-04.
Note: Reimbursement is 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. The TRICARE Program
does not pay for the room and board charges of the
nursing home.
3.1.1.6 Inpatient Respite Care
The hospice is 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) is based upon 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 is only provided
on an occasional basis and then only if it is part of the overall treatment
plan. The interdisciplinary treatment group determines the
appropriateness and frequency of respite care. Only those respite
days which are actually paid at the inpatient respite rate are counted toward
the inpatient limitation (e.g., a respite
stay of 15 days is only reimbursed
for five days of inpatient respite care, and as such, only those
five days are counted toward the inpatient
limitation).
3.1.1.7 General Inpatient Care
Payment at the inpatient rate is made
when general inpatient care is provided. None of the other fixed payment
rates (i.e., RHC) are 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) is based upon the
geographic location of the hospice.
3.1.6
Cap
on Overall Reimbursement
Each TRICARE-approved
hospice program is 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 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
is 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, is 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. However, the
individual is to be
counted in the cap calculation for the following year, because the
election occurred after September 27.
3.1.6.1.4 The hospice shall
report the number of TRICARE beneficiaries electing
hospice care during the “cap period” to the contractor within
30 days after the end of the “cap period.”
3.1.6.1.5 The cap amount is adjusted
annually by the percent of increase or decrease in the medical expenditure
category of the Consumer Price Index for all urban consumers (Consumer
Price Index-Urban (Wage Earner) (CPI-U)).
3.1.6.1.6 DHA obtains the
adjusted cap amount from CMS
prior to the end of each cap period and provides it to
the contractor.
3.1.6.1.7 Payments in excess of the cap
amount are refunded by the hospice
program.
3.1.6.2 Determining
Number of Elections
The hospice
shall adhere to the following rules in
determining the number of TRICARE beneficiaries who have elected
hospice care during the period:
3.1.6.2.1 The beneficiary has not 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 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, the beneficiary
shall 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
is proportional
application of the cap amount when a beneficiary elects to receive
hospice benefits from two or more different TRICARE-certified hospices.
A calculation
is 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 determine the
proportionate LOS for all preceding hospices.
3.1.6.2.4.2 The contractor shall also
disseminate this
information to any other contractors having jurisdiction for hospices
in which the beneficiary was previously enrolled.
Note: While the crossing
of contractor jurisdictional areas (care in hospices located in
different jurisdictional areas) is relatively
rare, it may 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 shall use
Item 38 (CMS 1450 UB-04) of the admission notice to indicate the
transferring hospice’s complete name, address, and provider number.
The contractor shall determine the method
of reporting. The contractor shall
share the information with
the other contractor as soon as possible
after the demise of the beneficiary so that the other contractor has 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 upon 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
Use
the following guidelines 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
is reported.
3.1.6.4.1.1 If the beneficiary entered
the hospice before September 28, the fractional beneficiary is included
in the current cap year.
3.1.6.4.1.2 If the beneficiary entered
the hospice after September 27, the fractional beneficiary is 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 the TRICARE Program,
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 the TRICARE Program 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 upon 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, shall not exceed 20 percent 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 is 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
processes the
claims) determines
not to pay the inpatient
rate
, any days for which the hospice
receives payment at a home care rate
are not
counted
as inpatient days.
Note: The contractor
shall review the accuracy of the billing and the
appropriateness of the care as part
of the contractor medical review process. The contractor shall only look for
trends/patterns on a random sampling of claims.
3.1.7.4 The
contractor
shall calculate the inpatient limitation
servicing
the hospice as follows:
3.1.7.4.1 The maximum allowable number
of inpatient days are 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 is necessary.
3.1.7.4.3 If the total number of days
of inpatient care exceeded the maximum allowable number, the limitation
is 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
are 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
is 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 the TRICARE Program,
the hospice reports 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 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
has 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 or general supervisory
nature.
|
|
|
|
|
|
|
3.
|
Total reimbursement received
and receivable for general inpatient care and inpatient respite
care furnished to TRICARE beneficiaries for the period from 11/01/____
through 10/31/____.
|
|
|
|
|
|
|
4.
|
Aggregate number of TRICARE
inpatient days for both general inpatient care and inpatient respite
care for the period from
11/01/____ through 10/31/____.
|
|
|
|
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a.
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Aggregate number of TRICARE
routine days for the period from 11/01/____ through 10/31/____.
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b.
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Aggregate number of TRICARE
continuous home care hours for the period 11/01/____ through 10/31/____.
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5.
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Aggregate total number of days
of hospice care provided to all TRICARE beneficiaries for the period
from 11/01/____ through
10/31/____.
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SIGNATURE
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DATE
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TITLE
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3.1.10 End
of
Year Reconciliation
The contractor shall calculate 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
is taken directly
from the
data report form which
the hospice submits 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 validate 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 year
calculations shall be minimal since
the hospice reports 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) are subject
to the cap amount (i.e., it is 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 bills 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
has 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 The contractor
shall send refund checks to
the DHA CRM Directorate. If the hospice fails to submit the refund,
the contractor shall issue two additional demand letters sent
out at appropriate intervals as required by the TOM. The
contractor shall not send copies of the demand letters to
the beneficiary, and shall not place providers 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, the contractor shall transfer recoupment
cases to DHA in compliance with the
TOM.
3.1.12 Billing Procedures
Completion of the CMS 1450
UB-04 for hospice care. The following is information needed for completion
of those items required for the billing of hospice care. Items not
listed need not be completed unless otherwise required in double
coverage situations.
3.1.12.1 Item
1 - Provider Name, Address, and Telephone Number Required
Enter name, city, state, and ZIP
Code. The post office box number or street name and
number may be included. The state may be abbreviated using standard
post office abbreviations.
3.1.12.2 Item
4 - Type of Bill (TOB) Required
This three digit code gives
three specific pieces of information. The first digit identifies
the type of facility. The second digit classifies the type of care.
The third digit indicates the sequence of this bill in this particular
episode of care (referred to as a “frequency” code).
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Code Structure
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first
Digit - Type of Facility
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08 - Special (Hospice)
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second
Digit - Classification
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1 - Hospice (Nonhospital-Based)
2 - Hospice (Hospital-Based)
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third
Digit - Frequency Definition
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1 - Admit Through Discharge
Claim
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Use this code for a bill encompassing
an entire course of hospice treatment for which you expect reimbursement (i.e.,
no further bills shall 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 are
not 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 Rural Farm District (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 is not 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 shall be
the same date as the effective date of the hospice election, or change
of election. The date of admission shall not
precede the physician’s certification by more than two 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, Skilled Nursing Facility (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 the TRICARE Program.
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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 the TRICARE Program,
and where the primary payer has made payment at the time of billing the TRICARE Program.
If the primary payer has denied payment, indicate this with zeros
in the value amount. Enter the date of the denial and occurrence
code 24 in the appropriate field. The value codes are two numeric
digits, and each value allows up to eight numeric digits (000000.00).
If more than one value code is shown for a billing period, show
codes in ascending numeric sequence. There are four lines of data:
a, b, c, and d. Use Items 39a through 41a before Items 39b through
41b (i.e., the first line is used up before the second line is used).
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Code
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Title
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Definition
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12
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Working Age/Beneficiary/Spouse with
Employer Group Health Plan (EGHP)
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This code indicates the amount
shown in that portion of a higher priority EGHP payment that you
are applying to covered TRICARE charges on this bill.
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13
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End Stage Renal Disease (ESRD)
in the 12-month coordination period with an EGHP
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This code indicates the amount
shown is that portion of a higher priority EGHP payment made on
behalf of an ESRD beneficiary that you are applying to covered TRICARE
charges on the bill.
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14
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Automobile, No-Fault or Any Liability
Insurance
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This code indicates the amount
shown is that portion of a higher priority automobile, no-fault
or liability insurance payment made on behalf of a TRICARE beneficiary
you are applying to covered TRICARE charges on this bill.
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15
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Worker’s Compensation (WC) including
Black Lung (BL)
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This code indicates the amount
shown is that portion of a higher priority WC insurance payment
made on behalf of a TRICARE beneficiary you are applying to covered
TRICARE charges on this bill.
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16
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Department of Veterans Affairs (DVA)/Veterans
Health Administration (VHA), Public Health Service (PHS), Other Federal
Agency
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This code indicates the amount
shown is that portion of a higher priority DVA/VHA, PHS, or other
Federal Agency’s payment made on behalf of a TRICARE beneficiary
that you are applying to covered TRICARE charges on this bill.
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3.1.12.14 Item
42 - Revenue Code Required
3.1.12.14.1 Assign a revenue code for each
reimbursement rate. Enter the appropriate three digit numeric revenue
code on the adjacent line in column 42 to explain each charge in
column 43.
Note: Use revenue
code 657 to identify the charges for services furnished to patients
by physicians employed by, or receiving compensation from the hospice.
In conjunction with revenue code 657, enter the appropriate physician
CPT procedure codes in Item 44. CPT procedure codes are required to
ensure the contractor makes allowable
charge determinations when reimbursing hospice physicians.
3.1.12.14.2 Use these revenue codes to
bill
the TRICARE
Program.
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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 (shall be
accompanied by a physician CPT procedure code)
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3.1.12.15 Item
46 - Units of Service Required
Enter the number of units for
each type of service on the line adjacent to the revenue code and description.
Units are measured in days for codes 651, 655, and 656, in hours
for code 652, and in procedures for code 657.
3.1.12.16 Item 47 - Total Charges Required
Enter the total charges for
the billing period by revenue code (column 42) on the adjacent line
in column 47. The last revenue code entered in column 42 represents
the grand total of all charges billed. The total is in column 47
on the adjacent line. Each line allows up to eight numeric digits
(000000.00).
3.1.12.17 Item
50A, B, C - Payer Identification Required
If the TRICARE Program is
the only insurer other than Medicaid and TRICARE Supplemental
Plans, the TRICARE Program is
the primary payer. Enter the correct contractor in line 50A. If
there are other insurers besides Medicaid and TRICARE supplemental
plans, the TRICARE Program 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 the TRICARE Program,
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 the TRICARE Program 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 the TRICARE Program,
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, Clinical Modification (ICD-10-CM) 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-CM 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 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 Form
Locator (FL) 45, line
23. A hospice representative shall ensure 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
are considered institutional care
for payment and reporting purposes. The special rate code “P” (TRICARE
Systems Manual (TSM),
Chapter 2, Section 2.8)
is 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
are converted
to the appropriate TYPE OF INSTITUTION code provided in the TSM,
Chapter 2, Addendum D. Code 81
is converted
to 78 (non-hospital based hospice) and code 82
is converted
to 79 (hospital-based hospice).
3.1.13.2.2 The third digit
is 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)
allow
hospice institutional claims to by-pass all cost-sharing edits.
3.1.13.4 The revenue code 0657
is 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) are 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 are paid
at 100 percent 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
allow
s hospice
non-institutional claims (hospice physician charges) to by-pass
all cost-sharing edits and to be paid at 100
percent of
the
CHAMPUS Maximum Allowable 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) are reported
on an institutional claim format while hospice physician services
(revenue code 657 and accompanying CPT procedure codes) are reported on
a non-institutional claim format. The claim is 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,
are billed
in
the provider’s own right.
3.1.13.6.1 Independent attending physician
or NP services are subject to standard
TRICARE allowable charge methodology (i.e., subject to standard
deductible and cost-sharing provisions).
3.1.13.6.2 The physician specialty code
(TSM,
Chapter 2, Addendum C)
is reported
on the
TRICARE Encounter Data (TED
)
records.
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 The provider
shall bill non-hospice services 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
ensure:
• Non-related
hospital admissions, nonhospice TRICARE coverage is provided to
a beneficiary only when hospitalization was for a condition not
related to the beneficiary’s 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 (e.g., it
is not unusual for a terminally ill patient to develop pneumonia
or some other illness as a result of the beneficiary’s weakened
condition). Similarly, the setting
of bones after fractures occur in a bone cancer patient are treatment
of a related condition. The treatment of these related conditions
is part of the overall hospice benefit, and as such, are not 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 review 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. The
contractor shall reimburse these Basic Program services 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.