New Problems for Hospice Care in PA/LTC Settings

September 24th, 2014 by Rod Baird

This week’s blog focuses on new complexities for LTC Medical Groups, Facilities, and Pharmacies, secondary to CMS’ 2015 Hospice rules.  Many LTC Patients also receive Hospice Services.  CMS efforts to limit provider payments outside of the Hospice Benefit will complicate life for facility staff, LTC pharmacies, and any Medical provider not named as the (single) Hospice Attending Physician.

Why is a blog on PA/LTC Medical Practice Management discussing Hospice rules? Simple – billing for encounters with Hospice patients in PA/LTC settings after 10/1/2014 will require precise adherence to existing billing rules to avoid (A) denials, or (B) fraud/abuse investigations. The following excerpt from CMS’s August 22nd (8/22/2014) final rule 2015 Hospice Payment Regulations is sending a clear message: CMS believes Hospice Services are being unbundled, a threat to Program Integrity. Is anyone else listening?

50464 Federal Register / Vol. 79, No. 163 / Friday, August 22, 2014

Recent analysis of other Part A, Part B and Part D spending in 2012 (including beneficiary cost-sharing payments of $135.5 million for Parts A and B and $48.2 million for Part D) shows that there was an additional $1 billion in total Medicare spending during a hospice election (see section III.A.4). This includes Part A payments for inpatient hospitalizations and SNF stays, as well as Part B payments for outpatient and physician services, diagnostic tests and imaging, and ambulance transports. There is concern that many of these services should have been provided under the Medicare hospice benefit as they very likely were for services related to the terminal illness and related conditions. This strongly suggests that hospice services are being “unbundled”, negating the hospice philosophy of comprehensive, holistic care and shifting the costs to other parts of

Medicare, and creating additional cost-sharing burden to those vulnerable Medicare beneficiaries who are at end-of-life. Duplicative payments for hospice-covered services also threaten the program integrity and fiscal viability of the hospice benefit.

Background: The initial Hospice rules were written well before end of life care merged into the mainstream of the continuum. At one time Hospice care was an ‘other’ service; something that few people used, and unrelated to the balance of our healthcare system. Referrals were limited to terminal Cancer patients with very limited life expectancy. You crossed a care-chasm getting to the Hospice Benefit. Almost all care was given by the Hospice staff, so few reimbursement problems arose.

Fortunately for end of life patients, times changed. Advocates for End of Life Care inserted Hospice into the fabric of our healthcare delivery system – all for the better. Now Nursing Home, and some Hospital patients receive Hospice care during a facility stay. Unfortunately Medicare hasn’t ever adapted its regulations to acknowledge a Hospice patient in a Facility/Institutional setting is likely to receive Medical Care from a panel of interrelated providers.

Scope of the Problem: Most of the Nursing Homes our large LTC Medical Practice serve, maintain a Collaborative Relation with one or more Hospice provider. In most cases, one of our LTC Physicians is named the Hospice Attending Physician, but an NP, PA and on-call staff may also provide care. For our LTC Medical Practice, about 6% of all our claims are for Nursing Home Patients receiving Hospice Services, which is a drop from previous years. We suspect earlier CMS initiatives that focused on contracting between Hospices and Nursing Facilities dampened the use of Hospice. According to Medicare, in CY 2012, 28.3% of Hospice Beneficiaries were residing in a Nursing Facility.

Defining the Issues: In CMS’ eyes, nothing has changed since 1983 when the final Hospice Regulations were codified. Providers aren’t following those rules; improper claims are being submitted to, and paid by, Medicare Parts A, B and D.

The 2015 edition of the regulations are clarifying existing rules to remove any possible ambiguity. When the draft rules came out in the early summer, our billing/compliance team began testing our own procedures. We discovered significant confusion between the facilities, hospices, medical groups and pharmacies regarding both claims management and authority/responsibility.

Eventually, we met with the Coding Consultant of a large hospice to sort out the regulations. Here’s what we determined. Following the regulation precisely will have significant implications for all existing Business/clinical models where nursing facilities, LTC medical groups and unrelated hospice service providers interact. Traditional workflows are subject to interruption, and payment denials are likely. Based on the language of the 2015 Hospice regulations, almost all services for Hospice patients after 10/1/2014 must be paid by the Hospice Provider, not directly by Medicare.

Explaining the subtleties and complexities of the interaction between SNF/NF, Hospice and Medicare Part B rules will take many words. Only a few readers may want to follow this regulatory labyrinth, which I’ll cover in the next blog post. So below are the bottom line rules for Part B Billing when a patient has elected the Hospice Benefit. They apply to both the Medical Staff and ancillary facility services:

Question 1: Do you have patients in your PA/LTC setting whom may need/want access to Hospice Services?

(A) No – stop reading, this doesn’t apply to you

(B) Yes – go to #2

Question 2: Has a particular patient who is a candidate for Hospice officially made the hospice election?

(A) No – bill as usual until the election is signed

(B) Yes – determine the following:

—–Who did the patient elect as the hospice attending physician? This is a legal election, executed in writing by the patient or their Healthcare Proxy.

—–What was the Principal Hospice Diagnosis? This is the diagnosis supplied by the Hospice Attending Physician as part of the official Hospice Care Plan.

After the Patient’s hospice election, new rules for claims submission and payment apply.

Question 3: Who can bill Medicare Part B when treating the patient for Medical problems after the Hospice election?

(A) For problems related to the Principal Hospice Diagnosis, only the Hospice Attending Physician can submit claims to Part B for services. Claims submitted by that provider must use the GV modifier. (The Hospice Billing rules do acknowledge a concession for other Physicians working with the Hospice Attending Physician).

Chapter 11 – Processing Hospice Claims/ 40 – Billing and Payment for Hospice Services Provided by a Physician – 40.1.3 – Independent Attending Physician Services

If another physician covers for a hospice patient’s designated attending physician, the

services of the substituting physician are billed by the designated attending physician

under the reciprocal or locum tenens billing instructions. In such instances, the attending physician bills using the GV modifier in conjunction with either the Q5 or Q6 modifier.

Claims by any other provider for problems related to the Principal Diagnosis require a direct contract with the patient’s Hospice agency. If submitted to Part B, they are likely to be denied be at time of submission of on during retrospective audits.

(B) Problems unrelated to the Principal Hospice Diagnosis may be treated by other providers and paid by Medicare Part B. These claims require use of the GW modifier. Next week’s post will include a more detailed discussion of CMS’s definition of ‘related vs. unrelated diagnoses’. Their position is clear; almost all medical problems experienced by a Hospice patient are related to their terminal illness.

Here are the rules in a simple table format:

Role↓ Treatable Diagnoses Modifier Required on Claim
Hospice Attending Physician All diagnoses GV modifier (Physician has been elected as Attending Physician and visit was related to terminal diagnosis – Physician is not employed by Hospice)
Substitute Attending Physician All diagnoses GV modifier+ Q5 or Q6 modifier
Other Medical & Health Providers Diagnoses not related to the Hospice Principal Diagnosis GW modifier (visit was not related to Hospice diagnosis)

Next week’s Blog will delve into the additional regulatory complexities secondary to these more precise rules. Of particular concern is the updated definition of Principal Hospice Diagnosis and related conditions.

Again, thanks for reading these blog posts and feel free to comment; we are all learning together!


Rod Baird

About Rod Baird

Rod Baird is the Founder and President of Geriatric Practice Management (GPM). Since 1977, he’s led provider and management organizations that deliver care to Medicare/Medicaid beneficiaries. Past programs he’s overseen include home health, personal care, hospice, rehabilitation hospitals, adult and psych daycare, alcohol/drug rehabilitation, industrial medicine and primary care practices. The Centers for Medicare and Medicaid Services (CMS) selected Baird as one of only 73 individuals to serve with its InnovationProgram. His educational background includes a Master’s Degree in Physical Chemistry from the American University, Washington, D.C.

We're ready to help you. Contact us today by phone at (828) 348-2888, or get in touch via our contact form.