Updates and Clarifications to the Hospice Policy Chapter of the Benefit Policy Manual. Compliance for Hospice Providers Revised September 2014

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1 Compliance Update National Hospice and Palliative Care Organization Regulatory & Compliance Updates and Clarifications to the Hospice Policy Chapter of the Benefit Policy Manual Compliance for Hospice Providers Revised September 2014 CMS issued CR 8877, Hospice Manual Update for Diagnosis Reporting and Filing Hospice Notice of Election (NOE) and Termination or Revocation of Election on August 22, 2014 with an effective date of October 1, This CR rescinds and fully replaces CR This Change Request provides a manual update and provider education for new editing for principal diagnoses that are not appropriate for reporting on hospice claims. It also provides contractor requirements, a manual update, and provider education for newly required timeframes for filing a hospice notice of election, and a hospice notice of termination/revocation of election, and for the exceptions process available when a hospice notice of election is filed late. It also provides a clarification of the differences between Healthcare Common Procedure Coding System (HCPCS) site of service codes Q5003 and Q5004. Every hospice provider should take a few minutes to read CR8877 to become familiar with the changes in Chapter 11 and update policies and procedures accordingly for compliance on October 1, Updates to Chapter 11 include the following: Timely Filing the Notice of Election (NOE): NOEs shall be filed within 5 calendar days after the hospice admission date. A timely filed NOE is a NOE that is submitted to the Medicare contractor and accepted by the Medicare contractor within 5 calendar days after the hospice admission date. What is considered timely-filing? Provider penalty for NOE s not filed timely Identifying noncovered, provider liable days A timely-filed NOE is one that is submitted to and accepted by the Medicare contractor within 5 calendar days after the hospice election. Day one = first day after the hospice admission date. The date of posting to the CWF is not a reflection of whether the NOE is considered timely-filed. Medicare shall not cover and pay for the days of hospice care from the hospice admission date to the date the NOE is submitted to, and accepted by, the Medicare contractor. These days shall be a provider liability, and the provider shall not bill the beneficiary for them. The hospice shall file the associated claim with occurrence span code 77 used to identify the non-covered, provider liable days and charges related to the level of care for these days shall be reported as noncovered, or the claim will be returned to the provider. 1 National Hospice and Palliative Care Organization, 2014

2 Bill type and method of filing Exceptions for timely-filing Identifying an exception for timely-filing Exception determination Final claim Type of bill 8xA. Entered via Direct Data Entry (DDE). A provider may request an exception which, if approved, waives the consequences of filing a NOE late. The four circumstances that may qualify the hospice for an exception to the consequences of filing the NOE more than 5 calendar days after the hospice admission date are as follows: 1. Fires, floods, earthquakes, or other unusual events that inflict extensive damage to the hospice s ability to operate; 2. An event that produces a data filing problem due to a CMS or Medicare contractor systems issue that is beyond the control of the hospice; 3. A newly Medicare - certified hospice that is notified of that certification after the Medicare certification date, or which is awaiting its user id from its Medicare contractor; or, 4. Other circumstances determined by the Medicare contract or CMS to be beyond the control of the hospice. Even when claiming an exceptional circumstance as the cause of its late-filed NOE, the hospice shall file the associated claim with occurrence span code 77 used to identify the non-covered, provider liable days. The hospice shall also report a KX modifier with the Q HCPCS code reported on the earliest dated level of care line on the claim. The KX modifier shall prompt the Medicare contractor to request the documentation supporting the request for an exception. Based on documentation, the Medicare contractor shall determine if a circumstance encountered by a hospice qualifies for an exception. If the request for an exception is approved by the Medicare contractor, it will process the claim with the CWF override code and remove the submitted provider liable days, which will allow payment for the days associated with the late-filed NOE. If the Medicare contractor finds that the documentation does not support allowing an exceptional circumstance, it will process the claim as submitted. Hospices continue to have 12 months from the date of service in which to file their claims timely. Timely Filing the Notice of Election Termination / Revocation (NOTR): If a hospice beneficiary is discharged alive or if a hospice beneficiary revokes the election of hospice care, the hospice shall file a timely-filed Notice of Election Termination / Revocation (NOTR) unless it has already filed a final claim. An NOTR is the same as filing a final claim. What is considered timely-filing A timely-filed NOTR is a NOTR that is submitted to the Medicare contractor and accepted by the Medicare contractor within 5 calendar days after the effective date of discharge or revocation. Day one = first day after the effective date of discharge or revocation. The date of posting to the CWF is not a reflection of whether the NOTR is considered timely-filed. 2 National Hospice and Palliative Care Organization, 2014

3 Bill type and method of filing NOTR s not filed timely Final claim Type of bill 8xB. o Contains similar data elements to the NOE, but includes a through date which is the discharge date. Entered via Direct Data Entry (DDE). There is no provider liability penalty from CMS/ MAC for not filing a timely NOTR. Providers need to file NOTR s timely to avoid delays for the discharged patient to Part D medication access. Hospices continue to have 12 months from the date of service in which to file their claims timely. ICD-9-CM/ICD-10-CM Coding Guidelines: The principal diagnosis reported on the claim is the diagnosis most contributory to the terminal prognosis. Hospice providers must follow the ICD-9-CM/ICD-10-CM Coding Guidelines. CMS will implement a Medicare Code Editor edit beginning October 1, 2014 as a Manifestation code as principal diagnosis edit in the Integrated Outpatient Code Editor (IOCE). Additionally, new edits for the codes in Attachment A will be implemented, as these codes are part of sequencing or other coding convention in ICD-9-CM/ICD-10-CM coding guidelines. ICD-9-CM/ICD-10- CM codes that may not be used as primary diagnoses Return to provider claims Diagnosis codes that cannot be used as the principal diagnosis according to ICD-9-CM/ICD-10-CM Coding Guidelines. Diagnosis codes which require further compliance with various ICD-9- CM/ICD-10-CM coding conventions. Codes that have principal diagnosis code sequencing or etiology/manifestation guidelines. Diagnosis codes listed under the classification of Symptoms, Signs, and Ill-defined Conditions are not to be used as principal diagnoses when a related definitive diagnosis has been established or confirmed by the provider. Debility (799.3, /R53.81) and adult failure to thrive (783.7/R62.7) are not to be used as principal hospice diagnoses on the hospice claim form. Diagnosis codes in Attachment A When the above diagnoses are reported as a principal diagnosis, the claim will be returned to the provider for a more definitive hospice diagnosis based on ICD-9-CM/ICD-10-CM Coding Guidelines. ICD-9-CM/ICD-10-CM Dementia Coding Guidelines: ICD-9-CM/ICD-10- CM dementia codes that may not be used as primary diagnoses Codes that have principal diagnosis code sequencing guidelines. o Most of these dementia codes are those found under the ICD-9- CM/ICD-10-CM classification, Mental, Behavioral, and Neurodevelopmental Disorders as these are typically manifestations from an underlying. Diagnosis codes /F o Dementia in diseases classified elsewhere without behavioral disturbance, and /F02.81, Dementia in diseases classified 3 National Hospice and Palliative Care Organization, 2014

4 elsewhere with behavioral disturbance. Unspecified codes These codes are only to be used when the medical record, at the time of the encounter, is insufficient to assign a more specific code. Return to provider claims o it is recognized that the underlying neurologic causing dementia may be difficult to code because the medical record may not provide sufficient information. There are codes listed under Diseases of the Nervous System that do provide for appropriate principal code selection under these circumstances and hospice providers are encouraged to look at the coding conventions under that classification for coding dementia s on hospice claims. When the above diagnoses are reported as a principal diagnosis, the claim will be returned to the provider for a more definitive hospice diagnosis based on ICD-9-CM/ICD-10-CM Coding Guidelines. Clarification - site of service HCPCS codes Q5003 and Q5004: CMS clarified the differences between site of service HCPCS codes Q5003 and Q5004, and replaced the previous description of the differences with the following language. This clarification does not represent a change in policy regarding the correct usage of Q5003 and Q5004. HCPCS code Q5004 HCPCS code Q5003 Q5004 shall be used for hospice patients in a skilled nursing facility (SNF), or hospice patients in the SNF portion of a dually- certified nursing facility. There are 4 situations where this would occur: 1. If the beneficiary is receiving hospice care in a solely - certified SNF. 2. If the beneficiary is receiving general inpatient care in the SNF. 3. If the beneficiary is in a SNF receiving SNF care under the Medicare SNF benefit for a unrelated to the terminal illness and related s, and is receiving hospice routine home care; this is uncommon. 4. If the beneficiary is receiving inpatient respite care in a SNF. If a beneficiary is in a nursing facility but doesn t meet the criteria above for Q5004, the site shall be coded as Q5003, for a long term care nursing facility. Attachment A. Hospice Invalid Principal Diagnosis Codes: The diagnosis codes on Attachment A may not be used as primary hospice diagnoses effective October 1, Additionally, new edits for the codes in Attachment A will be implemented, as these codes are part of sequencing or other coding convention in ICD-9-CM/ICD-10-CM coding guidelines. Reference: Change Request Hospice Manual Update for Diagnosis Reporting and Filing Hospice Notice of Election (NOE) and Termination or Revocation of Election, (2014, August 22), Centers for Medicare and Medicaid Services, retrieved from: Guidance/Guidance/Transmittals/Downloads/R3032CP.pdf 4 National Hospice and Palliative Care Organization, 2014

5 Attachment A - Hospice Invalid Principal Diagnosis Codes ICD-9-CM DESCRIPTION ICD-10-CM DESCRIPTION Senile Dementia Uncomplicated Presenile Dementia Uncomplicated Presenile Dementia With Delirium Presenile Dementia With Delusional Features Presenile Dementia With Delusional Features Presenile Dementia With Depressive Features Senile Dementia With Delusional Features Senile Dementia With Delusional Features Senile Dementia With Depressive Features Senile Dementia With Delirium Senile Dementia With Delirium Vascular Dementia Uncomplicated Vascular Dementia With Delirium Vascular Dementia With Delusions Vascular Dementia With Depressed Mood Other Specified Senile Psychotic Conditions Unspecified Senile Psychotic Condition F01.50 Vascular Dementia. F01.51 Vascular Dementia w/ behav. Disturb. F01.51 Vascular Dementia w/ behav. Disturb. F01.51 Vascular Dementia w/ behav. Disturb. 5 National Hospice and Palliative Care Organization, 2014

6 293.0 Delirium Due To Subacute Delirium Psychotic Disorder With Delusions In F06.2 Psychotic disorder w/ delusions d/t known s Psychotic Disorder With Hallucinations In Other Specified Transient Organic Mental Disorders Due To Conditions Classified Dementia, Unspecified, Without Behavioral Disturbance Dementia, Unspecified, With Behavioral Disturbance F06.0 Psychotic disorder w/ hallucin. d/t known Mood disorder d/t know disorder 0 Subcategories of 1 Subcategories of 2 Subcategories of 3 Subcategories of 4 Subcategories of F06.1 Catatonic disorder d/t know F03.91 Unspecified dementia w/ behav. Disturb 6 National Hospice and Palliative Care Organization, 2014

7 294.8 Other Persistent Mental Disorders Due To Conditions Classified Other Persistent Mental Disorders Due To Conditions Classified Frontal Lobe Syndrome Personality Change Due To Conditions Classified Postconcussion Syndrome F06.0 Psychotic disorder w/ hallucin. d/t known F06.8 Other specified mental disorders due to known F07.0 Personality Change D/T Known Physiological Condition F07.0 Personality Change D/T Known Physiological Condition F07.81 Postconcussional Syndrome Other Specified Nonpsychotic Mental Disorders Following Organic Brain Damage Unspecified Nonpsychotic Mental Disorder Following Organic Brain Damage F07.89 Other Personality And Behavioral Disorders Due To F09 Unspecified Mental Disorder Due To Known Physiological 7 National Hospice and Palliative Care Organization, 2014