Federal News and Information:

Palmetto: Reminder to share with your billers.  This addresses new system edits to prevent billing gaps in hospice transfer, what happens when there is a billing gap, and how to handle transfers from out of services areas.

Gap Billing Between Hospice Transfers

There are new system edits to prevent gap billing between hospice transfers, additional instructions about hospice transfers to administer existing hospice benefit policy and revisions to Pub 100-04, Chapter 11, Section 20.1.3 – Change of Provider/Transfer Notice.  Please note that transfers and admissions from one provider to another has to happen the same day.  Any gaps will be rejected in the common working file!  These changes can be accessed at:https://www.cms.gov/files/document/mm12619-gap-billing-between-hospice-transfers.pdf.

Share with your billers:

Hospices are to Report Post-Mortem Visits with the Modifier PM

  • Medicare is finding through the Medical Review process that hospices are not correctly reporting post-mortem visits with the modifier PM on their claims. These reporting errors will be counted as an error in the review process and may cause service intensity add-on (SIA) payments to be applied incorrectly on the claim. Once a person dies, there is no level of care anymore.
  • Hospices shall report visits and length of visits (rounded to the nearest 15-minute increment), for nurses, aides, social workers and therapists who are employed by the hospice, that occur on the date of death, after the patient has passed away, with modifier PM. The reporting of post-mortem visits, on the date of death, should occur regardless of the patient’s level of care or site of service. Post-mortem visits occurring on a date subsequent to the date of death are not to be reported.
  • Date of death is defined as the date of death reported on the death certificate. Hospices shall report hospice visits that occur before death on a separate line from those which occur after death.
  • For example, assume that a nurse arrives at the home at 9 p.m. to provide routine home care (RHC) to a dying patient, and that the patient passes away at 11 p.m. The nurse stays with the family until 1:30 a.m. The hospice should report a nursing visit with eight 15-minute time units for the visit from 9 p.m. to 11 p.m. On a separate line, the hospice should report a nursing visit with a PM modifier with four 15-minute time units for the portion of the visit from 11 p.m. to midnight to account for the 1 hour post mortem visit.
  • If the patient passes away suddenly, and the hospice nurse does not arrive until after his death at 11 p.m., and remains with the family until 1:30 a.m., then the hospice should report a line item nursing visit with a PM modifier and four 15-minute increments of time as the units to account for the 1 hour post mortem visit from 11 p.m. to midnight.

Resource: Medicare Claims Processing Manual, Chapter 11 — Processing Hospice Claims section 30.3 — Data Required on the Institutional Claim to A/B MAC (HHH)  at:  https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c11.pdf.

The following information was provided during the Palmetto Quarterly Update.  Any questions should be directed to CMS, VBID plans and VBID Model Team.

Accelerated and Advance Payment:

  • CMS created a temporary loan program to requesting providers and suppliers, including physicians and non-physician practitioners. These are not grants and providers requesting and receiving CAAP payments are required to pay back the funds as determined by CMS. Repayment did not begin for one year starting from the date of the accelerated or advance payment was issued. Beginning at one year from the payment was issued and continuing for 11 months, Medicare claims payments otherwise owed to providers and suppliers will be recouped at a rate of 25%.   After the 11 months end, Medicare claims payments otherwise owed to providers and suppliers will be recouped at a rate of 50% for another 6 months. After 6 months end, a letter for any remaining balance of the payments will be issued. After 30 days interest will accrue at the rebate of 4% from the date the letter was issued.
  • Can a provider determine how much CAAP they still owe? Palmetto sends out 1/4th emails/letters to providers regarding their outstanding balance. Last letter was sent 1/18/22, next will be 4/18/22. This will continue into 2023. Overpayment date is available for all lines of business. Accessing your real time overpayment balance achieved in four easy steps via the eServices portal (financial tools tab, overpayment data sub tab, input AR transaction # or demand letter, and submit).
  • Can the provider pay back early? Yes. You can pay at any time? You can do it via eCheck or with a hard copy check sent to Palmetto. But be sure to get the money into Palmetto mailroom 10 business days prior to the date the offset % increase takes place to prevent futures offsets from occurring.

Resources:

 

VBID Model Update:

Hospice providers could be affected by the VBID Model.

The hospice benefit is part of the larger VBID model, which has a 34 MA Organization providing care to approximately 3.7 million Medicare pts in 49 states, DC and Puerto Rico.   Its goal is to enable a seamless care continuum that improves quality and timely access to palliative and hospice care in a way that fully respects beneficiaries and caregivers. There is no change in payor.

Policies and Requirements:

  1. Participating MAOs must continue to cover hospice for enrollees who choose to elect hospice through an in- network (contract with the MAO provider) or out-of network (no MAO contract) hospice providers.
  2. Participating MAOs continue to be prohibited from applying any prior authorization to hospice care related to the enrollees terminal condition.
  3. Participating MAOs must continue to pay for out of network hospice care at 100% of original Medicare rates including physician services and the service intensity add on payments. They must cover the way original Medicare would.
  4. Participating MAOs must continue to pay for any unrelated services and/or post hospice live discharge costs, as long as they are deemed to be appropriate and medically necessary (as with original Medicare).
  5. Participating MAOs – only certain plan benefit packages offered by the participating MAOs are a part of the hospice benefit component.

Billing and Claims- Hospice providers must continue to send all notices and claims to both the participating MAO and the relevant MAC on a timely basis. The MAO will process payment and the MAC will process the claims for informational and operational purposes and for CMS to monitor the model. If the hospice contracts to provide hospice services with a participating MAO, CMS encourages the provider to confirm billing and processing steps before January 1, 2022, as they may be different. When the year changes, double check to ensure that the plan is still participating. Also check with your patient to see if their Medicare has changed. If a hospice chooses not to contract, the participating MAO must continue to pay the hospice provider at least equivalent to Original Medicare rates for Medicare covered hospice care.

Keep in mind that a patient may travel for their hospice care so you may see a patient enrolled in one of the participating plans offering coverage not in their service area. For example, only: a patient with coverage from a participating plan whose service area is in Ohio may travel to receive hospice care from a hospice provider in Fla, commonly called a “snowbird” or a “winter Texan” if traveling into Texas.  The provider should submit all notices and claims to the plan in Ohio. The hospice’s MAC will remain the same for the informational submissions.

Calculation of the aggregate cap and the inpatient cap: all billing related to care provided to an enrollee who have coverage thru a plan participating in the hospice benefit component should not be included in calculating a hospice’s progress toward the aggregate and inpatient cap. The payments from these plans will not be included in the cap.

Contacting the participating MAOs:

  1. Hospice providers should reach out directly to the participating MAO for any specific questions regarding processes related to claims and notifications submissions, claims, and notifications processing, clinical questions and network participation.
  2. Hospice providers can find the contact information of key plan staff (see resources below).

 

Please note the following information and resources.

 

Texas News and Information:

Texas Medicaid Healthcare Partnership

Preadmission Screening and Resident Review (PASRR); Form Action Buttons No Longer Available on Converted PL1

Form Action buttons on converted Preadmission Screening and Resident Review (PASRR) Level 1 (PL1) forms that might put the form(s) back into an active workflow will no longer be displayed to the users as of June 30, 2022. This change will help prevent outdated or invalid data from being copied into other PASRR forms. Users will be able to continue to use the following form action buttons:

  • Print
  • Print IDT
  • Add Note
  • Update Form (displayed for NF users only because they are documented as the PL1 submitters)

LTC Online Portal Unavailable at 9:00 p.m. on April 6 through April 12

The Long-Term Care (LTC) Online Portal will be unavailable due to system maintenance beginning Wednesday, April 6, 2022, at 9:00 p.m. through Tuesday, April 12, 2022, at 11:59 p.m. All web-based functions of the TMHP LTC Online Portal will be unavailable. All LTC Online Portal users will not be able to access the TMHP LTC Online Portal for form submission or workflow actions. LTC Online Portal account creation will be available, but providers will need to ensure account setup completion after the outage. Providers should complete LTC Online Portal form submissions by 12:00 p.m., on April 6, 2022, to ensure processing. Providers can verify eligibility and service authorization status using Medicaid Eligibility Service Authorization Verification (MESAV) during the outage. Note: Claims billing will not be impacted; LTC providers can continue to submit claims using electronic claims submission methods.

 

Disclaimer:  The Texas and New Mexico Hospice Organization publishes the Regulatory Update as an information only item.  TNMHO has no attorneys nor does it represent the state and federal governments.  All legal questions or concerns should be directed to your attorney or the governments involved.