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 equals 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/____.
|
|
|
|
|
|
|
a.
|
Aggregate number of TRICARE
routine days for the period from 11/01/____ through 10/31/____.
|
|
|
|
|
|
|
b.
|
Aggregate number of TRICARE
continuous home care hours for the period 11/01/____ through 10/31/____.
|
|
|
|
|
|
|
5.
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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 allows 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.