brief overview of coding and billing hospice medical benefits
DESCRIPTION
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. - PowerPoint PPT PresentationTRANSCRIPT
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
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