CMS Issues New Condition Code for Use When Hospice Recertification Is Untimely; also Corrects Hospice “Claims” Processing Problems
August 9, 2016 03:52 PM
The Centers for Medicare & Medicaid Services (CMS) has released Change Request (CR) 9590, New Condition Code To Use When Hospice Recertification Is Untimely and Corrections to Hospice Processing Problems, dated August 5. This CR creates a new condition code – 85 -- to be used when the hospice received the recertification of terminal illness later than 2 days after the first day of a new benefit period. This code is reported with occurrence span code (OSC) 77, which reports the provider liable days associated with the untimely recertification. The requirement becomes effective January 1, 2017.
Historically Medicare systems have ensured that occurrence code 27 (the hospice certification date) could not be reported within the OSC 77 dates. However, since October 2014, Medicare regulations have required that hospice Notices of Election (NOEs) shall be filed within 5 calendar days after the hospice admission date. In instances where a NOE is not timely-filed, Medicare does not cover 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 are a provider liability, and the provider may not bill the beneficiary for them. The requirements for the NOE include use of OSC 77 to report provider liable non-covered days when the NOE was not submitted within 5 days. Medicare systems compare incoming hospice claims to the NOE receipt date and enforce the presence of OSC 77 for the appropriate dates. An occurrence code 27 date within the OSC span dates in the case of an untimely NOE is perfectly appropriate, but currently Medicare systems cannot distinguish between when the OSC 77 is used for purposes of a late NOE or a late recertification. CMS is implementing the new condition code 85 to identify a late recertification so that Medicare systems will be able to distinguish between whether the provider-liable days declared by the provider are due to a late certification or to a late Notice of Election (NOE), and to allow the hospice certification date (designated by occurrence code 27) to be included on the claim in conjunction with OSC 77 dates in cases where the NOE is untimely.
The new condition code 85 is effective on January 1, 2017,and is defined "Delayed recertification of hospice terminal illness." When hospices report this code, Medicare systems will ensure the occurrence code 27 date does not fall within the OSC 77 dates.
Also as part of CR 9590, CMS is correcting other systems problems related to the new hospice payment system for routine home care (RHC) and the service-intensity add-on (SIA), some of which have been discussed previously. These system problems (which will also be corrected effective January 1, 2017) include:
Systems not counting all hospice benefit period days when the period is not separated by 60 days for purposes of determining whether a high or low RHC payment should be paid;
Systems not looking back at a prior month’s claim in some situations to determine if there are SIA-eligible visits that should be paid; and
Systems incorrectly recouping SIA payments in error if a provider subsequently adjusts the claim again.
CR 9590 will also address situations in which hospice claims in transfer situations are being returned to provider in error because a NOE from a previous hospice was note filed timely. Please note that until this CR becomes effective, the Medicare Administrative Contractors (MACs) have been instructed to override the edit that is currently occurring in error.