CMS Hospice Attending Physician Regulations

October 10th, 2014 by Rod Baird

Two weeks ago this blog covered the direct impacts of the new 2015 Hospice regulations on LTC Attending Physicians. My research on this topic began with a seemingly simple question from a SNF Medical Director about flagging improper Principal Hospice Diagnoses in our EHR. CMS published a list of Symptoms, Signs, and Ill-defined Conditions are not to be used as principal diagnoses. The final rule went on to enumerate the exact ICD-9 codes that are prohibited for use by the Hospice.

What follows is a list of issues, each of which could fill an entire post, that anyone (Facility, Physician, Pharmacy, Hospice) might want to consider:

How do you know if a Patient has Elected Hospice?
I work directly with large LTC Medical Groups and also design the logic behind an EHR specific to this market. Often during a year, a LTC Medical Group will assume the role of SNF/NF attending Physician when beginning to serve a new building. Based on multiple interviews, there is no standardized way for identifying hospice patients in PA/LTC settings. Some facilities in non-CON states have 3 or more hospices covering a single building. Most Facility EHRs don’t have a standard location for Hospice Status. What is needed:

    • Who is the Hospice Attending Physician,
    • what is the Principal Hospice Diagnosis, and
    • which Hospice is responsible for the patient’s care?

CMS reports that ~28% of all Hospice patients receive care in a SNF/NF setting. There are going to be a significant number of prescriptions that will be paid by the Hospice, not the SNF or Medicare Part D. The NCPDP is in the process of developing rules to efficiently categorize medications by their relation to the Hospice Principal Diagnosis, but there is no current standard for actually communicating the Hospice election from the LTC Facility to the Pharmacy; Hospice admission doesn’t show up in a standard ADT message, nor in the NCPCP Census Message. More work is needed to avoid erroneous claim submission.

As a SNF/NF – if the patient elects Hospice who do you call for problems? We’ve been asked this by multiple facilities. They are cautious about accepting existing Hospice patients, not knowing who is supposed to manage a patient’s condition under the new rule. If the Hospice Attending Physician is not available, does the facility call the Physician’s On-call system, or the Hospice?

What if a Medical Provider other that the Hospice Attending Physician, or an Hospice employee treats the patient for a problem related to the Hospice Principal Diagnosis? I believe they call this Charity care. Medicare can’t be billed directly. It is possible for the Facility or Medical Group to negotiate a contract directly with the Hospice for required patient care. Note that Hospices can bill Medicare directly for Specialty Physician Services required to treat issues related to the Principal Diagnosis. I understand that Hospice claims submitted to Medicare Part A for NP/PA services are not considered Covered Services – so asking the Hospice to pay for NP/PA services may be contentious. Looking to Hospice for payment also creates additional work, and billing issues for the LTC Medical Group:

  • Negotiating contracts for with each Hospice. For Covered services Part A will pay the lower of the submitted charge or 100% of the Fee Schedule. This is a ‘pass through’ service.
  • Correctly changing the patient’s primary payor from Medicare B to the Hospice when the Hospice election is made.
  • Choosing the correct diagnosis – when the Hospice is paying, the claim must list the Principal Hospice Diagnosis.
  • Enduring a growth in A/R (no Hospice we know has ever paid as quickly as Medicare Part B), All claims are paper based, to remittances are posted manually.
    • A possible benefit from this arrangement is a reduced risk of audit

What role do LTC Nurse Practitioners Play in serving Hospice patients? Even more confusing! Under the Hospice rules, a patient can designate a NP as their Attending Physician. In that case the NP becomes the only non-hospice employee able to directly bill Part B for services related to the Hospice principal Diagnosis. In my opinion, NPs can still bill Medicare for primary, or specialty, care unrelated to the Hospice Principal Diagnosis. Again, they need to be aware of that diagnosis, and use the correct modifier. (Note – this is where many billing departments go awry – the Practice may employ the Hospice Attending Physician and ‘team’ care with NPs and PAs. If they aren’t acutely aware of the required changes in primary diagnosis and Modifier Codes, submitted claims will appear to be improper in the eyes of CMS).

Are there Special Rules for Group Practices?
Yes, the CMS Policy Manuals describe how group practice submit Part B claims for Hospice Attending Physician Services – Medicare Claims Processing Manual, Ch. 1, 30.2.10 – Payment Under Reciprocal Billing Arrangements – Claims Submitted to Carriers. This describes the fundamentals of claims submission, but neglects to address Group practices with NPPS.

Is there any more information for Group Practices about using the Q5 modifier? Does this provision allow NP or PA staff to cover for the Hospice Attending Physician? My last blog post mentioned the existing CMS Claims Processing regulations that contain provisions for a substitute Physician to cover for the Hospice Attending Physician (this could be a Physician from the same group – modifier Q5, or a Locum Tenens Physician – modifier Q6).

Researching this topic has consumed a significant amount of time, and led to contradictory advice. Some very large hospice providers, with knowledgeable leaders, report that it is acceptable practice for the Medical Group employing the Hospice Attending Physician to use NP or PA staff in their stead. Other billing consultants were unaware of this provision in the regulation, and felt it was erroneous.

I have found NO CMS or MAC written guidance on this question. If it is a compliant strategy, then this does solve many problems for LTC Medical groups with mixed staff covering the facility. However, because the regulation specifically identifies Physicians (by title) as the type of provider to which this regulation applies, and not an NPP, we have concerns about compliance. We’ve written to CMS seeking guidance (i.e. can a group’s NP cover for the Hospice Attending Physician and group bill Part B using the GV + Q5 modifiers). If any reader has written guidance from CMS or a MAC on this question, please let me know.

How do these rules affect NP only LTC Medical Groups? One of the practice patterns we see frequently, at least east of the Mississippi, is an increasing number of NP only groups. These are springing-up where there is a dearth of full time LTC Physician services. Those NPs may be employed by an independent entity, or the LTC Facility. These NPs work in collaboration with the PCP who admits, and recertifies the patient’s need for Nursing Facility level care. Based on the new rule, it is acceptable for one of the NP Group’s staff to be designated as the Hospice Attending Physician. That will cause a problem with the Nursing Facility Attending Physician (not employed by the NP group). If the NP is the Hospice Attending Physician, the NF Attending Physician can’t bill directly to Medicare Part B. The Facility is still required to have that Physician provide the minimum frequency of Regulatory visits to the patient to satisfy Survey & Certification.

In the SNF/NF, do Hospice Regulations override Survey & Certification rules? This is my personal opinion, not based on deep research. In a word – NO. A PA/LTC entity is always subject to its State facility regulations, and the Survey & Certification process. At the same time, a patient on the Hospice benefit is subject to Medicare payment rules, and Hospice Survey & Certification rules. When there are conflicts, follow the Facility’s regulations; hope for payment but realize some services will be non-covered. That is a problem when

What is considered the Hospice Principal Diagnosis? CMS goes to great length to tell HOSPICES what CANNOT be used as a Principal Diagnosis.

Hospice Manual Update for Diagnosis Reporting:

The principal diagnosis reported on the claim should be the diagnosis most contributory to the terminal prognosis. The coding guidelines state that when the provider has established, or confirmed, a related definitive diagnosis, codes listed under the classification of Symptoms, Signs, and Ill-defined Conditions are not to be used as principal diagnoses. ….. According to the ICD-9CM/ICD-10-CM Coding Guidelines both “debility” and “adult failure to thrive” are considered nonspecific, symptom diagnoses. Specifically, you should not use ICD-9-CM codes 799.3 (Debility, unspecified) and 780.79 (Other malaise and fatigue), ICD-10-CM code R53.81 (Other malaise); and ICD-9-CM code 783.7 and ICD-10-CM code R62.7 (adult failure to thrive) as principal hospice diagnoses on a hospice claim form.

Medical Groups are not immediately affected by this regulation, but I fully expect subsequent instruction will alert Part B providers that they too must follow the correct coding guidelines. Subsequently they exhort Hospices to list all of the related Diagnoses.

In the FY 2014 Hospice Wage Index and Payment Rate Update final rule, we reported that for the first quarter of FY 2013 (October 1, 2012 through December 31, 2012) 72 percent of hospice claims only reported a single, principal diagnosis (78 FR 48240). We also discussed related versus unrelated diagnosis reporting on claims and clarified that ‘‘all of a patient’s coexisting or additional diagnoses’’ related to the terminal illness or related conditions should be reported on the hospice claim. Information on a patient’s related and unrelated diagnoses should already be included as part of the hospice comprehensive assessment and appropriate interventions should be incorporated into the patient’s plan of care, as determined by the hospice IDG.

If a LTC Medical Group submits Medicare Part B claims for a patient receiving Medicare Hospice Services after 10/1/2014, they should have a strategy in place to both identify the Principal Diagnosis, and decide if the GV modifier (related to the Hospice principal diagnosis) or GW (unrelated to the Hospice principal Diagnosis applies. Here is how CMS instructed Pharmacies and Part D plans to identify conditions related to the Hospice Principal Diagnosis.

Q18: Is there a definition of “related condition”?

A18: In the FY 2014 hospice final rule, CMS clarified that all of a patient’s coexisting or additional diagnoses related to the terminal illness and related conditions should be reported on the hospice claim. We also stated that when an individual is terminally ill, many health problems are brought on by underlying conditions, as bodily systems are interdependent, meaning that there are multiple conditions, and hence diagnoses, contributing to the terminal prognosis (78 FR 48247). Our expectation is that hospices will follow ICD-9-CM coding guidelines for listing all diagnoses for the terminal illness and related conditions on the hospice claim.

Do the new guidance on Principal Diagnosis make it more difficult to qualify a LTC patient for Hospice?

CMS’ new definitions of Principal Hospice Diagnosis preclude the use of many diagnoses related to debility and cognitive impairment. But, it is still possible to qualify this group of patients for Hospice Coverage; the physician simply needs to reference the underlying condition, not the symptom. Here is a link to an excellent post on the Geripal blog, authored by Shaida Talebreza Brandon that explains that principal.

Once we receive any feedback from CMS about the proper protocols for reporting team care shared between Physicians and NPPS, I’ll update this post.


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.

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