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Hospice Series Part 3: CMS Change Request 8358


Hospice Series part 3: CMS Change Request 8358: Additional Reporting Requirements; Update on Medicare Part D Issue

This is the third article in our Hospice series, highlighting the many upcoming changes and issues that hospices are facing. This article will highlight the components of CMS Change Request (CR) 8358 –Additional Reporting Requirements for Hospice Claims and provide preliminary guidance for hospice providers. The "relatedness" issue significantly affects these reporting requirements, in particular as related to the line item billing for prescription injectable and non-injectable drugs.

In addition, we have an update on the Medicare Part D issue which has significant impact on providers, patients, and their families. It is imperative that hospices stay abreast of these evolving issues and take necessary steps to insure that they have processes in place to successfully meet these challenges.

CR 8358 Additional Reporting Requirements for Hospice Claims

The Highlights of CMS Change Request (CR) 8358-Additional Data Reporting Requirements for Hospice Claims include the following:

Effective Dates:

  • January 1, 2014: Voluntary reporting for claims with dates of service on or after 1/1/14. Voluntary claims will be submitted to the Medicare Administrative Contractor (MAC) beginning January 6, 2014.
  • April 1, 2014: Mandatory reporting for claims with dates of service on or after 4/1/14.
     

Additional Reporting Requirements Overview:

  • Hospice staff visit data for General Inpatient (GIP) level of care in SNFs and Hospitals:
    • Hospices must report all hospice staff nursing, PT, OT, ST, Hospice Aide as well as Social Work (visits and calls) in 15 minute increments for patients in skilled nursing facilities receiving skilled care (site of service HCPCS code Q5004) and hospitals (site of service HCPCS codes Q5005, Q5007, Q5008).
    • There are no changes to the GIP visit reporting requirements when the site of service is a hospice inpatient unit.
  • NPI Number of Facility where Hospice Patient is Receiving Services:
    • Hospices must report the NPI of a nursing facility, hospital and hospice facility where the patient is receiving services when the service is not performed at the same location as the billing hospice’s location, regardless of level of care provided.
    • If the patient receives service in more than one facility in a month, the hospice must report the NPI of the facility where the patient was last treated.
  • Post Mortem Visits:
    • Hospices must report the services provided to the patient/family after the patient’s time of death if the visits occur on the same calendar day. All visits occurring on the same calendar day of the patient’ death after the pronounced time of death will be billed with a PM modifier.
    • Visits that occur on a date subsequent to the date of death are not to be reported on the claim.
  • Reporting Injectable and Non-Injectable Prescription Drugs:
    • Injectable drugs are reported on a line item basis per fill using revenue code 0636 and the applicable HCPCS code.
    • Non-Injectable Prescription Drugs are reported on a line item basis per fill using revenue code 0250 the applicable NDC (National Drug Code).
    • Over the Counter medications are not required to be reported on the claim.
  • Reporting Infusion Pumps:
    • Hospices must report infusion pumps on a line-item basis for each pump order using revenue code 029X and the appropriate HCPCS code.
    • Hospices must report the infusion medication on a line-item basis for each refill using revenue code 0294 along with the appropriate HCPCS.
    • DME other than infusion pumps are not to be reported at this time.

There are many outstanding questions related to this requirement. The MACs have compiled questions to which CMS is in the process of responding. The MACs and the state/national associations will provide hospices with updated information as it becomes available.

It is anticipated that these processes with have a significant impact on daily hospice operations. Providers will need to evaluate the impact of these requirements and find ways to streamline operations to maintain compliance with not only with these requirements but also for the multitude of upcoming changes that will affect reimbursement, financial and clinical operations.

In anticipation of these changes, Simione recommends the following strategies for your organization:

  1. Stay informed through your MAC, state and national associations regarding additional clarification and responses to the questions posed to CMS.
  2. Contact your software vendor to determine their state of readiness for these important changes and their contingency plans to meet the new requirements. Keep in mind that many of the outstanding questions pertain to process details that software vendors will need to have in order to initiate some of the changes. This will undoubtedly affect the timeframe for implementation of the requirements.
  3. Work with your pharmacy vendor to ensure they are aware of the changes and are prepared to provide the needed codes to your organization. The pharmacy will need to be able to provide this information quickly to avoid delays in hospice billing and cash flow. In addition, your organization can also develop a process for online look up of HCPCS and NDC codes to facilitate receipt of this information.
  4. Provide ongoing education to staff and managers regarding the additional reporting requirements, as well as the other changes which impact the hospice agency and staff.
  5. Conduct an evaluation of your current hospice operations (policies, procedures, documentation, work flow and personnel) to identify what changes will need to be made to meet the new requirements. Remember to include all of the upcoming quality reporting, coding and cost reporting changes and the impact on your hospice’s compliance activities. This is a key area of importance for hospice operations in preparing for the changes.
  6. Develop a work plan within your organization to address operational issues necessary to meet the new requirements. These are sweeping changes, so it is imperative that departments and staff across your entire organization be included in the work plan. Note that the work plan will need to be flexible and evolve as additional information is received from CMS. 

Simione has a team of hospice experts who can assist with all aspects of hospice operations and service delivery and can assist with operational reviews and education to assist your organization in successfully navigating this changing hospice landscape.  Contact Simione to see how we can assist you with your hospice needs. 800-949-0388 or[email protected]

Update on Medicare Part D Issue

On December 6, 2013 CMS released draft guidance for Part D Payment for Drugs for Beneficiaries enrolled in hospice. Comments are due to CMS on January 6, 2014 at 12 Noon.  The guidance document can be found athttp://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospice/Downloads/Hospice-PartD-Payment.pdf. Simione Healthcare Consultants is providing this update as a follow up to our Hospice Series Part 1 Article: “Medicare Part D Guidance Creates Significant Issues for Hospice Providers.”

This is the latest chapter in one of the most significant issues facing hospice providers today and further brings into the spotlight the determination of what is related versus not related to the palliation and management of the terminal illness and related conditions. The Key Points in this draft guidance include the following:

  • Medicare is reiterating that most medications should be payable under the hospice benefit and that CMS expects that drugs covered under Part D for hospice beneficiaries will be extremely rare.
  • The draft guidance provides different scenarios under which medications may be paid for by either the hospice provider, Medicare Part D sponsor, or by the patient and what would be covered.
  • The draft guidance establishes a requirement that the Medicare Part D sponsors implement a prior authorization and appeals process.
  • CMS is proposing the implementation of an independent reviewer process in the event that either the hospice or the Medicare Part D sponsor request further appeal. The findings from the CMS independent reviewer process would be considered final.
  • If a hospice uses a formulary, CMS expects hospices to provide non-formulary drugs if they are determined to be necessary for the palliation and management of the terminal illness and related conditions.
  • CMS is proposing the use of an Advanced Beneficiary Notice (ABN) when the patient requests that the hospice provider pay for a medication that the beneficiary requests for his or her terminal illness or related conditions that is not on the hospice formulary and the beneficiary refuses to try a formulary equivalent first; or it is determined by the hospice provider to be unreasonable or unnecessary for the palliation of pain and/or symptom management. Delivering an ABN in these situations will allow the patient to assume financial responsibility for the drug. Under these circumstances, no payment for the drug will be available under Medicare Part D.

More information will be forthcoming from CMS and the state and national associations in the coming weeks. Simione will continue to stay on top of this significant issue and provide real-time guidance to providers on how all of these changes and requirements will impact daily operations.

Contact Simione for further information and to see how we can assist you with your hospice needs. 800-949-0388 or [email protected]