Brief Overview of Coding and Billing Hospice Medical Benefits PRESENTED BY LORI DAFOE, CPC 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 choice MD or DO NP NOE (Notice of Election) An Attending Physician Can Be… Non-employee -no relationship with the Hospice Employee -Employed -Volunteered -Contracted Agreements with Consulted Physicians Written Agreement Identify Services Stipulation of Authorization from the Hospice Documentation Requirements Qualifications 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 services Medicare Part B for Physician Care Plan Oversight Technical services are covered under hospice’s daily rate Subject 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/month CPT 99378: > 30 minutes/month Attending Physician Non-Hospice Employee 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) Non-Attending Non-Hospice Employee Hospice Where 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) performed Medicare Part A will reimburse hospice 100% of the Medicare allowable amount Hospice reimburses the physician based on agreement between both parties ---Medicare is not involved Reimbursement for a Consulting Physician Same as an employed attending physician Contract 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 Physicians Normally billed to Medicare Part A on the clinic bill Hospice must contract with the physician and bill as a consultant physician Nurse Practitioners NPs 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 303.2 All 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/clm104c1 1.pdf THANK YOU!