brief overview of coding and billing hospice medical benefits

PRESENTED BY LORI DAFOE, CPC

Brief Overview of Coding and Billing Hospice Medical

Benefits

Hospice Services

Misconceptions about Medicare Hospice Benefit Coverage

Physician Services

Misconceptions

Patients must have DNR to access hospice.

Once a patient revokes the HMB (Hospice Medical Benefits), he cannot receive hospice care again.

Misconceptions

After 6 months on the hospice benefit, the patient is no longer eligible for hospice care.

When a patient goes to a hospital, hospice services cease.

Misconceptions

Patients who revoke or are discharged from hospice are “on their own.”

Managed care doesn’t pay for hospice.

Misconceptions

Once a patient elects hospice, he may no longer access other health insurance.

Misconceptions

Self insured companies don’t pay for hospice.

Can hospice agencies bill for Nurse Practitioners services?

Here’s the Scoop

There are a variety of misconceptions and misinformation about physician services.

Basic Concept

Traditional Medicare is exchanged for Medicare Hospice Benefit for care related to the terminal diagnosis.

Medicare Part A continues to provide coverage for related diagnoses or conditions treated in the in patient hospital setting

Who is the Attending Physician?

Patient’s choiceMD or DONPNOE (Notice of Election)

An Attending Physician Can Be…

Non-employee-no relationship with the Hospice

Employee-Employed-Volunteered-Contracted

Agreements with Consulted Physicians

Written AgreementIdentify ServicesStipulation of Authorization from the

HospiceDocumentation RequirementsQualifications of Personnel

Financial Responsibilities

Professional Management Responsibilities

How are the Services Categorized?

Professional Services

Administrative Services

Technical Services

Professional Services

Actual procedures performed by the physician as designated by the appropriate CPT Code

Only separately billable services

Administrative Services

Participating in the establishment, review, and updating of the Plan of Care (POC)

Care Plan Oversight

Supervising care and services

Evaluating therapies

Assessing need for treatment changes

Technical Services

X-rays, labs, and any other non-professional services

Reimbursed through the hospice’s daily rate

Reimbursement from the hospice is based on an agreement with the physician

Reimbursement for a Non-employee Attending Physician

Medicare Part B for professional servicesMedicare Part B for Physician Care Plan

OversightTechnical services are covered under

hospice’s daily rateSubject to deductible, then 80% Medicare

payment and 20% patient co-insurance

Administrative Services Provided by the Non-employed Physician

Care plan Oversight is billed by the physician to the Medicare Part B Carrier

At least 30 minutes face-to-face services must be provided in the month.

Medicare does not pay for oversight services provided in the nursing home

Activities and time spent must be documented.

CPT 99377: 15-29 minutes/monthCPT 99378: > 30 minutes/month

Independent attending physician may bill Medicare Part B for visits.

GV modifier – used when an independent attending physician is providing a service that is related to the terminal diagnosis.

If another physician covers for a hospice patient’s designated attending, the services are billed by the designated attending physician under the reciprocal or locum tenens billing instructions (using modifier Q5 or Q6, in addition to the GV)

Attending Physician Non-Hospice Employee

Non-Attending Non-Hospice Employee

HospiceWhere the service is related to the hospice patient’s terminal illness but is furnished by someone other than the designated “attending physician” (or physician substituting for the attending) the physician must look to the hospice for payment.

Reimbursement for an Employed Attending Physician

Physician bills Hospice Verify service dates, diagnosis being treated,

and service(s) performedMedicare Part A will reimburse hospice 100%

of the Medicare allowable amountHospice reimburses the physician based on

agreement between both parties---Medicare is not involved

Reimbursement for a Consulting Physician

Same as an employed attending physicianContract must be on record prior to

rendering the service, and before filing the professional charges to Medicare Part A.

NOTE: Medicare Part B will not reimburse any physician rendering related services to a hospice patient other than the non-employee attending physician.

Other Situations

Rural Health Clinic PhysiciansNormally billed to Medicare Part A on the

clinic billHospice must contract with the physician and

bill as a consultant physician

Nurse PractitionersNPs are only billable if providing services on

behalf of the non-employed attending physician

Billed to Medicare Part B Carrier

Unrelated Physician Services

HCFA Publication 21, Section 303.2All services unrelated to the terminal

condition and related conditions are billable to traditional Medicare for coverage consideration

GW Modifier - used when a physician is providing a service that is not related to the diagnosis for which a patient has been enrolled into hospice. This physician is not associated with the hospice and is providing services as a private physician.

Physician Billing Flowchart

References

http://www.aahpm.org/http://www.capc.org/http://www.cms.gov/http://

www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c11.pdf

THANK YOU!