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View this email online! Hospice Notes, 12/23/2015 View Previous Issues!


IN CASE YOU MISSED IT, Recent Hospice Headlines In NAHC Report...

NAHC, Affiliates Seek Input for 2016 Legislative, Regulatory Agendas

The policy staffs of the National Association for Home Care & Hospice (NAHC) and its affiliates—the Hospice Association of America (HAA) and the National Medicaid Action Council—are in the process of developing their agendas for legislative and regulatory activities in the coming year. NAHC, along with its affiliated organizations, is seeking member input with regards to crafting the 2016 agenda documents.

The policy staffs are seeking input to help develop these blueprints, which provide the action plans and basis for advocacy efforts for the coming year. Throughout the year as issues develop, NAHC, HAA, and the National Medicaid Action Council gather ideas for these agendas from members, state association affiliates, advisory committees, and the NAHC Board of Directors.

With potential big changes on the legislative and regulatory horizon for next year on Capitol Hill, NAHC and its affiliates are planning ahead as always with strategies to protect the continued viability of home care and hospice. Please take a moment to communicate your thoughts for these agendas to guide us as an association and a community.

As references, the 2015 Legislative and Regulatory Blueprints, as well as a document containing NAHC’s 2015 Legislative Priorities, are available below.

When the draft blueprints and legislative priorities for 2016 are completed, they will be reviewed by the NAHC Government Affairs Committee, the Hospice Advisory Board, the National Medicaid Action Council Board of Directors, and the NAHC Board of Directors.

To submit ideas to be considered for inclusion in the 2016 Legislative and Regulatory Blueprints for Action, please email

Please include:

  • A description of the issue;
  • Proposed recommendations; and
  • Your rationale for the change(s).

Please be sure to include your name and telephone number and/or email address in case we need to contact you for more information on the issue or proposal.

Watch the NAHC Member Listserv and NAHC Report for future updates.

HOSPICE NOTES is a National Association for Home Care & Hospice (NAHC) member benefit; to subscribe, go HERE.  Keep an eye on the NAHC Member Listserv and NAHC Report for updates on key hospice issues!  Subscribe HERE and HERE. Please have your NAHC member ID ready.

Hospice Routine Home Care (RHC) Level Of Care Payment Reform And Service Intensity Add-On (SIA) Visit Payment Q&As

Medicare hospice payment reforms go into effect January 1, 2016.  To assist providers, NAHC has developed a Q&A document on these reforms – routine home care (RHC) level of care payment reforms and service intensity add-on (SIA) payments.  The document can be viewed here.

Update on Expanded Home Health, Hospice Denial Reason Codes

The December 4 issue of NAHC Report included coverage of recent action by the Centers for Medicare & Medicaid Services (CMS) to expand the number of denial reason code statements available to the Medicare Administrative Contractors (MACs) for use in adjudicating home health and hospice claims.  The home health and hospice MACs began using the expanded list of denial reason code statements effective December 1, 2015.  At press time lists of the more than 80 detailed denial reason codes was not available; CGS, one of the  home health and hospice MACs, recently posted the lists to its website; they are available here:

Home Health:


CGS’ website further instructs that providers may access denial reason code definitions by accessing the denied claim using the Fiscal Intermediary Standard System (FISS) Claim Inquiry menu (Option 12), and pressing F1 to view the reason code narrative.

CMS Updates Program Integrity Manual

CMS Change Request (CR) 9438,  which updates the CMS Program Integrity Manual, has been posted.  This CR deals with the timeframes contractors have for pulling data from the esMD system.  Click here to read the full CR.

MedPAC to Recommend Zero Hospice Update for FY2017
Future discussions to include hospice in NF, variation in utilization by provider type

At its meeting held on December 10, 2015, the Medicare Payment Advisory Commission (MedPAC) discussed recent changes to the Medicare hospice benefit as well as reviewed data on payment adequacy and benefit utilization as part of its discussion on payment recommendations to be included in its annual March Report to Congress.  After consideration of these factors, the panel gave preliminary approval to a recommendation that Congress eliminate the hospice payment update for fiscal year (FY) 2017.  The Commission will meet in January to finalize its recommendations.   MedPAC plans to monitor the redistributional impact of the payment reform changes scheduled to go into effect on January 1, 2016, as part of future payment adequacy discussions.

As part of its deliberations on payment adequacy the panel reviewed factors related to access (including the supply of providers and volume of services provided), quality of care, access to capital, and hospice payments/costs.  This is the standard framework MedPAC uses when developing payment recommendations for all provider types.  MedPAC staff indicated that between 2013 and 2014:

  • The supply of hospices increased by 4 percent (driven by an increase in for-profit providers);
  • The percent of Medicare decedents using hospice increased by 0.5 percentage point;
  • The number of hospice users increased by 9,000;
  • Length of stay remains stable;
  • The hospice live discharge rate dropped by 0.8 percentage points; and
  • Access to capital appears to be adequate.

MedPAC staff projects that the financial margin for hospice providers in 2016 will be approximately 7.7 percent, as compared with an estimated margin of 8.6 percent in 2013.  The projected 2016 margin takes the following factors into consideration:  market basket, productivity, and other legislated payment adjustment; full elimination of the budget neutrality adjustment factor; and the sequester.  Staff noted that the financial margin calculation rate excludes the cost of bereavement and certain volunteer services, which would further reduce the financial margin by 1.7 percent at most. 

MedPAC also calculated a “marginal profit rate” for hospice providers of 12 percent; the “marginal profit rate” was defined as the degree to which Medicare payments exceed the cost of caring for an additional patient.  This was the first year that MedPAC discussions on hospice payment adequacy included calculation of a marginal profit rate.

In expanded discussions, the panel expressed an interest in future discussion of hospice care for patients in nursing facilities, including length of stay, higher profits, and resulting efficiencies for both hospice and nursing home providers.  Additionally, in light of differences in length of stay, margins, and other factors among different types of hospice providers, the panel expressed an interest in further discussion of hospice provider characteristics and business models.

It is anticipated that a transcript of the meeting and a copy of the presentation slides will be posted to the MedPAC webpage during the week following the December 10 - 11 meeting.

CBO Examines Medicare Per Beneficiary Spending
Growth in Hospice, SNF Use Increase Age Group with Highest Per Beneficiary Spending

The Congressional Budget Office (CBO) has issued a working paper, “Changes in Medicare Spending per Beneficiary by Age” that identifies “rapid growth in spending on SNF [skilled nursing facility] and hospice care and the increasing concentration of the use of hospice care among the very old” as accounting for “almost the entire increase in the age for which Medicare spending per beneficiary was highest.” Between 1999 and 2012, the age with the highest Medicare spending per beneficiary rose by almost a decade, from 87 to 96. Over the same time period, changes in spending on SNF care, hospice care, and acute inpatient care contributed substantially to the changes in the profile of Medicare spending per beneficiary by age. Specifically, spending on SNF and hospice care for all age groups rapidly rose, with an increasing concentration of hospice use among the very old, while use of acute inpatient care declined more rapidly for younger Medicare beneficiaries than for those aged 85 or older. It should be noted that before the late 1990s rapid growth in spending on home health and SNF care were drivers of the average growth rate in spending for very old beneficiaries; that appears to have shifted to a combination of hospice and SNF care in more recent years.

CBO points out that payment rules may have an impact on the quantity of services provided under Medicare, identifying payment for hospice services on a per diem basis (regardless of whether care is provided on that day) as an incentive for hospices to enroll healthier patients with less need for services. CBO notes that the growing percentage of hospice patients that are discharged before death may be a potential indication of inappropriate use of hospice care, but also cites studies positing that the growing use of hospice services may reflect a shift to more cost-effective end-of-life care.

The CBO study found that while growth rates of per-beneficiary spending on hospice care are progressively larger over the period studied (1999 - 2012) for older age groups, this is primarily due to the fact that use of these services is growing more rapidly among older beneficiaries than younger ones. All age groups saw a “striking increase in the annual cost of hospice care, with real spending on hospice care per user rising by more than 50 percent between 1999 and 2012” but “the differences in the increase in spending per user among the age groups were not very pronounced.” CBO identifies differential growth rates in the likelihood of hospice use among the different age groups (with older beneficiaries having a higher likelihood of using hospice) as contributing to the shift in the age profile of Medicare spending.

CMS Releases Plans to Use Payer-Only Occurrence Code for Late Face to Face Encounters

CMS released Change Request (CR) 9385 which creates a new payer-only occurrence code. The code will facilitate processing medical review determinations that some hospice services are denied due to an untimely face-to-face encounter.  Occurrence code 48 will be used by payers-only, not hospices, on claims. 

As is currently the practice, if the face-to-face encounter does not occur in a timely fashion, Medicare coverage ends and the hospice must discharge the beneficiary.   Once the encounter is complete, a new election of hospice services is required before the beneficiary can be readmitted by the hospice and continue covered services.  However, the codes the hospice enters on the claims do not terminate the patient’s current benefit period making it difficult for the hospice to submit a new notice of election (NOE).  In the case of a hospice record selected for medical review where the reviewer finds the untimely face to face encounter, the reviewer will assign occurrence code 48 to the claim.  When the partially-denied hospice claim is sent to the Common Working File (CWF), CWF will post the occurrence code 48 date as the revocation date on the current benefit. The hospice claim will be accepted by CWF with line item dates beyond the revocation date when occurrence code 48 is reported, as long as those line items are non-covered. This action will require the hospice to submit a new Notice of Election before any future dates of service can be submitted.  This CR does not introduce any new policy and will be implemented on April 4, 2016.

National Quality Forum Releases Measures Under Consideration

On December 2, 2015 NAHC Report included an article on the 2016 measures under consideration.  The measures are reviewed each year by the National Quality Forum’s (NQF) Measure Applications Partnership (MAP). The list of measures under consideration (MUC) includes two specific measures for the hospice quality reporting program (HQRP) and one other specifically for oncology patients receiving hospice care. There are also various other measures that mention hospice (either including or excluding the population in the measure calculation) but not directly impacting hospice quality data.

The measures are listed below along with the first round of comments NAHC submitted.  These comments were due December 7, and there will be more opportunity for comments as the MAP reviews the measures. Please send your feedback on hospice measures to Katie Wehri at

Hospice Measures Under Consideration

  • Hospice visits when death is imminent  - Assess hospice staff visits to patients and caregivers in the last week of life

Members of the hospice staff considered for the measure include: nurses (registered nurse, licensed professional nurse or nurse practitioner if acting in the role of a nurse), hospice aides, physicians (or nurse practitioner or physician assistant if acting as the attending physician), chaplains or spiritual counselors, therapists (physical therapist, occupational therapist or speech language therapist), medical social workers, and volunteers. General inpatient and continuous care visits made are excluded from this measure.

Currently, the visit data required for this measure is not currently gathered and reported by hospices.

Comment:  Hospices do not currently collect and report all the visit data that is included in this measure.  This creates a burden for those programs not having the capability/infrastructure to collect and report this data.  Any measure utilized in the HQRP must be properly vetted to ensure that it is, in fact, related to quality of hospice care to reduce the incidence of inappropriate conclusions that might be drawn from the measures. We believe claims-based measures are practice indicators that do not take into account the condition and other characteristics of the population served by a hospice.  A claims-based measure should not be used in the HQRP unless its direct relationship to hospice quality has been proven, and that connection can be readily drawn by the public.

  • Hospice and palliative care composite process measure - Assess percentage of hospice patients who received care processes consistent with guidelines at admission

This is a composite measure based on select measures from 7 NQF- endorsed measures: NQF #1641, NQF #1647, NQF #1634, NQF #1637, NQF #1639, NQF #1638, NQF #1617.  These measures are part of the HIS, and this composite process measure calculates the patients who meet the numerator criteria for all of the select measures of the above-referenced NQF measures. 

Comment:  This measure uses existing and readily available data and more closely aligned with hospice processes directly impacting quality of care.

  • Oncology measure: 

Proportion of patients admitted to hospice for less than three days - Percentage of patients who died from cancer, and admitted to hospice and spent less than 3 days there

Comment:  This MIPS measure is very good. Hospices have reported seeing an uptick in late oncology referrals as payment policies have changed. We recommend that it be considered for broader utilization by other provider types, for causes of death other than cancer, and the length of stay be extended to a longer timeframe.  Earlier referral to hospice means end-of-life pain and symptoms can be aggressively addressed and crises, such as hospitalizations, can be avoided.

NAHC also made comment on the advance care plan measure (MUC15 – 578).  The measure and comment are below.

Measure:  Advance care plan

Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan

Comment:  This measure for MSSP is a good starting point to promoting advance care planning, a necessary component to quality care.  We recommend that this measure be added to the quality programs of other provider types and, eventually, be expanded to include measures assessing provider compliance with patient’s advance directives

The first two measures above would be part of the HQRP.  The other measures would not be part of the HQRP.


The following two items were posted in recent days on the Hospice Quality Reporting Web Page:

HQRP Requirements for FY 2018 Reporting Year” Fact Sheet Now Available:  An “HQRP Requirements for FY 2018 Reporting Year” Fact Sheet is now available in the “Downloads” portion of the “Hospice Item Set (HIS)” section of the website. This fact sheet contains information about requirements for the Hospice Quality Reporting Program (HQRP) for the Fiscal Year (FY) 2018 reporting year (data collection period 1/1/16 - 12/31/16). These requirements include submission of both the Hospice Item Set (HIS) and the Hospice Consumer Assessment of Healthcare Providers and Systems (CAHPS®), as outlined in the fact sheet. (Posted Dec. 21, 2015)

“Timeliness Compliance Threshold” Fact Sheet Now Available:  A “Timeliness Compliance Threshold” Fact Sheet is now available in the “Downloads” portion of the “Hospice Item Set (HIS)” section of the Hospice Quality Reporting webpage or via this link.  This fact sheet outlines the timeliness compliance threshold for HIS submissions, finalized by CMS in the FY 2016 Final Rule, and presents a preliminary algorithm for the timeliness compliance threshold calculation. These policies go into effect for the FY 2018 reporting year, which begins January 1, 2016. (Posted Dec. 16, 2015)

The following three items were posted in recent days to the Hospice CAHPS Web Page: 

UPDATED: Technical Corrections and Clarifications to the CAHPS Hospice Survey Quality Assurance Guidelines V2.0 Document: An updated CAHPS Hospice Survey technical corrections and clarifications to the CAHPS Hospice Survey Quality Assurance Guidelines V2.0 document is now available. This document may be accessed by clicking here. A list of the new technical corrections and clarifications included in this document can be found on the Quality Assurance Guidelines page. The corrections/clarifications are as follow:

  • Removed text from Spanish materials (Updated 12/18/15)
  • Added language to Speaking with Caregiver section of the Telephone Script (Updated 12/18/15)
  • Clarification on defining the term “de-identified” (Updated 12/01/2015)
  • Removed the acronym “HHS” from Introduction section of the Telephone Script (Updated 12/01/2015)
  • Revised Question 2 Introduction and revised Questions 41 and 46 of the Telephone Script (Updated 12/01/2015)
  • Reordered and revised the End section of the Telephone Script (Updated 12/01/2015)

(Posted Dec. 18, 2015)

UPDATED: English (Telephone Script) and Spanish (Mail Materials and Telephone Script) Survey Instruments:  The CAHPS Hospice Survey Telephone Script in English and Spanish and the CAHPS Hospice Survey mail materials in Spanish have been updated. Details regarding the revisions can be found in the CAHPS Hospice Survey Quality Assurance Guidelines V2.0 Technical Corrections and Clarifications Document located on the Quality Assurance Guidelines page. To view or download a copy of the updated CAHPS Hospice Survey instruments, please click here. (Posted Dec. 18, 2015)

Participation Exemption for Size Page Updated:  The CAHPS Hospice Survey Project Team has updated the Participation Exemption for Size page to provide additional guidance for hospices requesting an exemption for size. It is anticipated that the period to begin requesting the Participation Exemption for Size for the calendar year 2015 will open in early January 2016. To view the updates, please click here. (Posted Dec. 18, 2015)


Claims with Anti-Cancer, Anti-Emetics will Process Starting Jan. 4

In August, the Centers for Medicare & Medicaid Services (CMS) issued Transmittal 1528/Change Request 9255, which addresses instances where hospice claims containing certain anti-cancer and anti-emetic drugs have been returned to provider (RTP).   Effective January 1, 2016, systems changes will be implemented that will allow all anti-cancer and anti-emetic drugs to process on hospice claims.  In the interim, hospices have been instructed to remove codes for these drugs from their claims.  Starting in January hospice providers should resume reporting of anti-cancer and anti-emetic drugs.

Both CMS and the Medicare Administrative Contractors (MACs) are encouraging hospices that removed these drugs from their claims so that the claims would process, beginning in early January,  to submit claim adjustments for all previous claims that should have included anti-cancer and anti-emetic drugs and that fall within the timely filing period.  While it is recognized that this will create additional work for hospice providers, it also means that drug data submitted by way of the hospice claims will be more accurate for purposes of determining drug costs in hospice, which could have some impact on future hospice payment decisions. 

For additional information, please refer to the MM9255 article here on the CMS website.


Over the last several months, NAHC Report has published information regarding a new Centers for Medicare & Medicaid Services (CMS) requirement that all prescribers of prescription medications that will be processed through the Part D program must be enrolled in Medicare in an approved status.  The requirement was scheduled to be applicable on June 1, 2015, but this date was delayed until January 1, 2016.  In a recent notice, CMS further postponed the requirement, which will now become applicable on June 1, 2016.

However, if you are a hospice physician/NP that prescribes medications that are processed through Part D (these prescriptions would be for conditions that are NOT related to the terminal or related conditions) and you are NOT enrolled in Medicare in an approved status, action should be taken before the end of 2015 to ensure sufficient time for processing of your enrollment so that your patients will not run into Part D processing issues when enforcement of the requirement begins on June 1, 2016. 

Following is information related to this issue that has been posted on the CMS Medicare Part D Prescriber webpage, along with additional resources:

Part D Prescriber Enrollment - About

If you're a physician or other eligible professional who writes prescriptions for Part D drugs, CMS regulations now require you to be enrolled in Medicare in an approved status.

The effective date for this requirement is June 1, 2016.  To allow Medicare Administrative Contractors (MACs) that process the applications enough time to enroll all prescribers and to ensure prescriptions are not denied, it is strongly recommended that prescribers of Part D drugs enroll by January 1, 2016.

What happens if I don't enroll?

Federal regulation requires all physicians and other eligible professionals who prescribe Part D drugs to be validly enrolled* in the Medicare program.  Part D plans will deny a pharmacy claim at point of sale for drugs prescribed by physicians or other eligible professionals who are neither enrolled in Medicare.* Enforcement of this provision is scheduled to begin on June 1, 2016; therefore, all prescribers should enroll by January 1, 2016, to allow for the processing of applications and to make sure enrollees get their prescriptions.

You can check your enrollment status using our online Enrollment File.  Here are the instructions for using the file to check enrollment.

* Physicians and other eligible professionals, except for prescribers for Medicare Advantage organizations, may validly opt out of Medicare.

Reporting of Hospice Aggregate Cap

Last year was the first year hospices needed to begin self-calculation and self reporting of their aggregate cap results.  The same requirements and process will be in effect for the 2015 cap year with calculation and reporting to be between January 31, 2016 and March 31, 2016.  MACs (Medicare Administrative Contractors) have not yet updated the portion of their website with the self reporting instructions for the 2015 cap year, but it is anticipated they will do so in the near future.  However, the process will be essentially the same as last year.  We will keep you informed as we get closer to the end of January and more information becomes available, but wanted to alert you to the fact that this is coming up soon.


  • Senate Finance Committee Chairman and Ranking Member Introduce Bill to Reduce Medicare Appeals Backlog, December 17, 2015
  • Urban Institute Study Advances Analysis of Federal Long-Term, December 10, 2015
  • Care Program Models
  • NAHC’s Medicaid Action Council to Governors: Support Nurses and  Caregivers Who Support Individuals Covered by Medicaid, December 9. 2015
  • Senate Passes Budget Reconciliation Legislation Repealing Affordable Care Act Provisions, December 7, 2015
  • CMS Expands Detail on Home Health, Hospice Denial Reason Codes, December 4, 2015
  • CMS Solicits Proposals for New RAC Contracts, November 26, 2015
  • Department of Veterans Affairs Proposal to Expand Private Health Care Arrangements, November 24, 2015
  • President Obama Signed Into Law Legislation Expanding the Program of All-Inclusive Care for the Elderly, November 20, 2015
  • Legislation Introduced Allowing Veterans to Receive Telehealth Services in Their Homes Across State Lines, November 20, 2015
  • Senate HELP Committee Approves Legislation Supporting Family Caregivers, November 19, 2015
  • Task Force on Medicaid Launched By House Energy & Commerce Committee Republicans, November 18, 2015

For questions about Hospice Notes, please contact its editors or authors
Theresa Forster, Vice President for Hospice Policy & Programs
Katie Wehri, Hospice Operations Expert

Please note that some links used in the production of the Hospice Notes are time-sensitive. These links may expire or require registration or fee-based subscriptions in order to access.

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