How can someone find a Medicare-certified
hospice program?
The National Hospice and Palliative Care
Organization (NHPCO) is committed to improving
end-of-life care and expanding access to hospice
care with the goal of profoundly enhancing quality of
life for people dying in America and their loved ones.
This organization, which represents most hospice
programs in the United States, has a hospice locator
program of its members. To find an NHPCO member
hospice, call NHPCO’s HelpLine at 1-800-658-8898
or log on to their web site at www.nhpco.org/database.
htm. Other ways to find Medicare-certified
hospice programs are through state hospice associations,
state health departments, or health care professionals
and clergy.
Showing posts with label Medicare basic. Show all posts
Showing posts with label Medicare basic. Show all posts
Monday, May 30, 2011
Wednesday, May 25, 2011
patient stop receiving hospice care
Why would a patient stop receiving hospice care?
A hospice patient has the right to stop receiving hospice
care at any time, for any reason. If the patient
chooses to stop hospice care, health care benefits from
the standard or managed care Medicare program continue.
On occasion, a terminally ill patient’s health
improves or the patient’s illness goes into remission
while receiving hospice care. A patient’s condition
may become stable to the point that the hospice team
and physician(s) believe the patient cannot be certified
as terminally ill (having a life expectancy of six
months or less), and, therefore, is no longer eligible for
the Benefit. At any point in time, a patient can
return to hospice care, as long as the eligibility criteria
is met and certification by physician(s) and hospice
team is received.
A hospice patient has the right to stop receiving hospice
care at any time, for any reason. If the patient
chooses to stop hospice care, health care benefits from
the standard or managed care Medicare program continue.
On occasion, a terminally ill patient’s health
improves or the patient’s illness goes into remission
while receiving hospice care. A patient’s condition
may become stable to the point that the hospice team
and physician(s) believe the patient cannot be certified
as terminally ill (having a life expectancy of six
months or less), and, therefore, is no longer eligible for
the Benefit. At any point in time, a patient can
return to hospice care, as long as the eligibility criteria
is met and certification by physician(s) and hospice
team is received.
Tuesday, May 17, 2011
Medicare HMO on hospice benefit will cover?
What if a patient is enrolled in a Medicare
managed care (HMO) plan?
A hospice-eligible patient who is enrolled in a
Medicare managed care plan may choose any
Medicare-certified hospice provider. Authorization
from the managed care plan is not required.
Can a patient change his or her
hospice provider?
Yes. A hospice patient has the right to change
hospice providers at any point, as long as the newlychosen
hospice program is Medicare-approved.
managed care (HMO) plan?
A hospice-eligible patient who is enrolled in a
Medicare managed care plan may choose any
Medicare-certified hospice provider. Authorization
from the managed care plan is not required.
Can a patient change his or her
hospice provider?
Yes. A hospice patient has the right to change
hospice providers at any point, as long as the newlychosen
hospice program is Medicare-approved.
Thursday, May 12, 2011
Medicare out of pocket for hospice care
What costs are covered and what are the
“out-of-pockets” to be paid by the patient?
Medicare pays the hospice directly for the patient’s
hospice care. Patients may have to pay no more than
5 percent — up to $5 for each prescription — for
outpatient drugs for pain relief and symptom control.
The hospice patient may also be responsible for 5
percent of the Medicare payment amount for inpatient
respite care.
Is a patient’s Medicare coverage forfeited if
hospice care is chosen?
Not at all. A patient retains full Medicare coverage
for any health care needs not related to the terminal
diagnosis, even if the patient elects hospice care. The
patient must continue to pay the applicable deductible
and coinsurance amounts under the standard Medicare
Plan or the copayment under a Medicare managed
care (HMO) plan.
How long can a patient receive hospice care?
For as long as the physicians continue to recertify the
terminal illness, patients can receive hospice care.
Two 90-day periods of care are followed by an unlimited
number of 60-day periods, as long as the patient
remains eligible. Hospice care is provided only to
patients who have been certified by their doctor and
the hospice medical director as terminally ill with a
life expectancy of six months or less.
“out-of-pockets” to be paid by the patient?
Medicare pays the hospice directly for the patient’s
hospice care. Patients may have to pay no more than
5 percent — up to $5 for each prescription — for
outpatient drugs for pain relief and symptom control.
The hospice patient may also be responsible for 5
percent of the Medicare payment amount for inpatient
respite care.
Is a patient’s Medicare coverage forfeited if
hospice care is chosen?
Not at all. A patient retains full Medicare coverage
for any health care needs not related to the terminal
diagnosis, even if the patient elects hospice care. The
patient must continue to pay the applicable deductible
and coinsurance amounts under the standard Medicare
Plan or the copayment under a Medicare managed
care (HMO) plan.
How long can a patient receive hospice care?
For as long as the physicians continue to recertify the
terminal illness, patients can receive hospice care.
Two 90-day periods of care are followed by an unlimited
number of 60-day periods, as long as the patient
remains eligible. Hospice care is provided only to
patients who have been certified by their doctor and
the hospice medical director as terminally ill with a
life expectancy of six months or less.
Tuesday, May 10, 2011
service not covered under Medicare program
What is not covered?
The following services are not covered under the
Medicare Hospice Benefit:
• Services for conditions unrelated to the terminal
illness, or
• Services for the terminal diagnosis that are not
called for in the hospice care plan or arranged for
by the hospice program.
Care that patients receive under the Medicare Hospice
Benefit for their terminal illness must be from a
Medicare-approved hospice program.
The following services are not covered under the
Medicare Hospice Benefit:
• Services for conditions unrelated to the terminal
illness, or
• Services for the terminal diagnosis that are not
called for in the hospice care plan or arranged for
by the hospice program.
Care that patients receive under the Medicare Hospice
Benefit for their terminal illness must be from a
Medicare-approved hospice program.
Saturday, May 7, 2011
Medicare hospice care - common question
Does the Benefit cover continuous care (a special level of hospice care) at home?
Yes. If there is a brief, acute episode that requires
additional care to manage pain or acute medical symptoms,
nursing care may be covered on a continuous
basis to maintain the patient at home. Skilled nursing
or home health aide services — or a combination of
both — may be covered on a 24-hour basis during
periods of crisis, but care during these periods must be
predominantly nursing care.
Does the Benefit cover general inpatient care
that may be needed as a result of a crisis or an
acute episode that cannot be handled in a
patient’s primary residence?
If a hospice inpatient admission is necessary for the
patient, the hospice team will arrange for the patient’s
stay in a freestanding hospice facility, a hospital, a
nursing home, or other long-term care facility, which
is covered by Medicare.
Is there any relief for loved ones whose responsibility
it is to care for the hospice patient?
Caregivers, who are family members or other loved
ones responsible for taking care of the hospice patient,
may, on occasion, need a break, or “respite,” from daily caregiving. To give the caregiver relief, respite care
may be provided in a Medicare-approved facility such
as a freestanding hospice facility, a hospital, a nursing
home or other long-term care facility, which is covered
by Medicare for up to five days at a time.
Yes. If there is a brief, acute episode that requires
additional care to manage pain or acute medical symptoms,
nursing care may be covered on a continuous
basis to maintain the patient at home. Skilled nursing
or home health aide services — or a combination of
both — may be covered on a 24-hour basis during
periods of crisis, but care during these periods must be
predominantly nursing care.
Does the Benefit cover general inpatient care
that may be needed as a result of a crisis or an
acute episode that cannot be handled in a
patient’s primary residence?
If a hospice inpatient admission is necessary for the
patient, the hospice team will arrange for the patient’s
stay in a freestanding hospice facility, a hospital, a
nursing home, or other long-term care facility, which
is covered by Medicare.
Is there any relief for loved ones whose responsibility
it is to care for the hospice patient?
Caregivers, who are family members or other loved
ones responsible for taking care of the hospice patient,
may, on occasion, need a break, or “respite,” from daily caregiving. To give the caregiver relief, respite care
may be provided in a Medicare-approved facility such
as a freestanding hospice facility, a hospital, a nursing
home or other long-term care facility, which is covered
by Medicare for up to five days at a time.
Thursday, May 5, 2011
Will medicare pay when hospice service given other POS
Will the Benefit pay for hospice care in a place
other than a personal residence?
Sometimes a patient does not or cannot reside in a
private home. The Benefit reimburses for hospice
services that are delivered in freestanding hospice
facilities, hospitals, and nursing homes and other longterm
care facilities. However, the Benefit does not
cover expenses for room and board. In some
instances, Medicaid may cover these expenses for eligible
patients. For benefits available under Medicaid,
consult your state Medicaid office.
other than a personal residence?
Sometimes a patient does not or cannot reside in a
private home. The Benefit reimburses for hospice
services that are delivered in freestanding hospice
facilities, hospitals, and nursing homes and other longterm
care facilities. However, the Benefit does not
cover expenses for room and board. In some
instances, Medicaid may cover these expenses for eligible
patients. For benefits available under Medicaid,
consult your state Medicaid office.
Monday, May 2, 2011
Service covered under Medicare hospice benefit
What services are covered under the Medicare
Hospice Benefit?
The Medicare Hospice Benefit (the Benefit) covers the
following services as long as they relate to the terminal
diagnosis and are outlined in the patient’s care plan:
• Physician services for the medical direction of
the patient’s care, provided by either the patient’s
personal physician or a physician affiliated with a
hospice program;
• Regular home care visits by registered nurses and
licensed practical nurses to monitor the patient’s
condition and to provide appropriate care and
maintain patient comfort;
• Home health aide and homemaker services such as
dressing and bathing that address the patient’s personal
needs;
• Chaplain services for the patient and/or loved ones,
if desired;
• Social work and counseling services;
• Bereavement counseling to help patients and their
loved ones with grief and loss;
• Medical equipment (i.e., hospital beds);
• Medical supplies (i.e., bandages and catheters);
• Drugs for symptom control and pain relief;
• Volunteer support to assist the patient and
loved ones;
• Physical, speech, and occupational therapy; and
• Dietary counseling.
Hospice Benefit?
The Medicare Hospice Benefit (the Benefit) covers the
following services as long as they relate to the terminal
diagnosis and are outlined in the patient’s care plan:
• Physician services for the medical direction of
the patient’s care, provided by either the patient’s
personal physician or a physician affiliated with a
hospice program;
• Regular home care visits by registered nurses and
licensed practical nurses to monitor the patient’s
condition and to provide appropriate care and
maintain patient comfort;
• Home health aide and homemaker services such as
dressing and bathing that address the patient’s personal
needs;
• Chaplain services for the patient and/or loved ones,
if desired;
• Social work and counseling services;
• Bereavement counseling to help patients and their
loved ones with grief and loss;
• Medical equipment (i.e., hospital beds);
• Medical supplies (i.e., bandages and catheters);
• Drugs for symptom control and pain relief;
• Volunteer support to assist the patient and
loved ones;
• Physical, speech, and occupational therapy; and
• Dietary counseling.
Saturday, April 30, 2011
Hospice Medicare benefits - who is eligible
Who is eligible for hospice benefits under Medicare?
Hospice benefits are available to Medicare beneficiaries
who:
• Are certified by their doctor and the hospice medical director as terminally ill and have a life expectancy of six months or less;
• Sign a statement choosing hospice care using the Medicare Hospice Benefit, rather than curative treatment and standard Medicare covered benefits for their terminal illness; and
• Enroll in a Medicare-approved hospice program.
It is important to note that Medicare will continue to pay for covered benefits for any health problems that are not related to the terminal illness.
Hospice benefits are available to Medicare beneficiaries
who:
• Are certified by their doctor and the hospice medical director as terminally ill and have a life expectancy of six months or less;
• Sign a statement choosing hospice care using the Medicare Hospice Benefit, rather than curative treatment and standard Medicare covered benefits for their terminal illness; and
• Enroll in a Medicare-approved hospice program.
It is important to note that Medicare will continue to pay for covered benefits for any health problems that are not related to the terminal illness.
Monday, April 25, 2011
Hospice care - how it is working.
How does hospice care work?
Typically, a loved one serves as the primary caregiver and, when appropriate, helps make decisions for the terminally ill individual. Members of the hospice staff make regular visits to assess the patient and provide additional care or other services. Hospice staff are on-call 24 hours a day, seven days a week.
The hospice team develops a care plan that focuses on the patient’s well-being and the need for pain management and symptom control. The plan outlines the medical and support services required such as nursing care, personal care (dressing, bathing, etc.), social
services, physician visits, counseling, and homemaker services. It also identifies the medical equipment, tests, procedures, medication and treatments necessary to provide high-quality comfort care.
The hospice team usually consists of:
• The patient’s family/caregiver;
• The patient’s personal physician;
• Hospice physician (or medical director);
• Nurses;
• Home health aides;
• Social workers;
• Clergy or other counselors;
• Trained volunteers; and
• Speech, physical, and occupational therapists, if needed
For more information on how to select a hospice program, see the National Hospice Foundation’s brochure, “Hospice Care: A Consumer’s Guide to Selecting a Hospice Program.”
Typically, a loved one serves as the primary caregiver and, when appropriate, helps make decisions for the terminally ill individual. Members of the hospice staff make regular visits to assess the patient and provide additional care or other services. Hospice staff are on-call 24 hours a day, seven days a week.
The hospice team develops a care plan that focuses on the patient’s well-being and the need for pain management and symptom control. The plan outlines the medical and support services required such as nursing care, personal care (dressing, bathing, etc.), social
services, physician visits, counseling, and homemaker services. It also identifies the medical equipment, tests, procedures, medication and treatments necessary to provide high-quality comfort care.
The hospice team usually consists of:
• The patient’s family/caregiver;
• The patient’s personal physician;
• Hospice physician (or medical director);
• Nurses;
• Home health aides;
• Social workers;
• Clergy or other counselors;
• Trained volunteers; and
• Speech, physical, and occupational therapists, if needed
For more information on how to select a hospice program, see the National Hospice Foundation’s brochure, “Hospice Care: A Consumer’s Guide to Selecting a Hospice Program.”
Saturday, April 16, 2011
Medicare Hospice Payment
Section 512(b) of the MMA amends section 1814(i) of the Act and establishes payment for this service. The statute specifies that the Medicare payment will be made to the hospice for services provided by the hospice medical director or physician employed by the hospice. The provision of these services may not be delegated to other hospice personnel (i.e., nurse practitioners, registered nurses, social workers, etc.) and may not be furnished by a physician under contract with the hospice. We intend to monitor data regarding the use of this benefit.
Since the evaluation and counseling provision is not a service within the hospice benefit, payment for these services are not included in the hospice payment cap.
Payment to the hospice agency for the provision of this evaluation and counseling service is made using HCPCS code G0337. The national payment amount for this service for FY 2005 will be $54.57. Future changes in the rate will be identified in the Physician Fee Schedules. See Pub 100-04, chapter 11, section 10.1 for claims processing instructions.
Since the evaluation and counseling provision is not a service within the hospice benefit, payment for these services are not included in the hospice payment cap.
Payment to the hospice agency for the provision of this evaluation and counseling service is made using HCPCS code G0337. The national payment amount for this service for FY 2005 will be $54.57. Future changes in the rate will be identified in the Physician Fee Schedules. See Pub 100-04, chapter 11, section 10.1 for claims processing instructions.
Wednesday, April 13, 2011
Hospice – Pre-Election Evaluation and Counseling Services
Effective January 1, 2005, section 512 of the MMA amends section 1812(a)(1)(5) of the Act which, provides for a one-time payment to be made to a hospice for evaluation and counseling services furnished by a physician who is either the medical director of or employee of a hospice agency. In order to be eligible to receive this service, a beneficiary must:
* be determined to have a terminal illness (which is defined as having a prognosis of 6 months or less if the disease or illness runs its normal course;
* not have made a hospice election, and
* not previously received the pre-election hospice services
Services under this benefit are comprised of:
* evaluating the individual’s need for pain and symptom management;
* counseling the individual regarding hospice and other care options, and may include;
* advising the individual regarding advanced care planning.
The services that comprise this benefit are currently available through other Medicare benefits. For example, evaluation and counseling are often provided by an individual’s
physician as well as by other sources such as discharge planners, case managers, social workers and nonphysician providers.
Therefore, this service may not be reasonable and necessary for all individuals. To the extent that beneficiaries have already received Medicare-covered evaluation and counseling with respect to end-of-life care, the hospice pre-election benefit would seem duplicative. However, if a beneficiary or the beneficiary’s physician deem it necessary to seek the expertise of a hospice medical director or physician employee, this benefit is available to assure that a beneficiary’s end-of-life options for care and pain management are addressed.
Since the decision to utilize this benefit is determined by the beneficiary or the beneficiary’s physician, the evaluation and counseling service may not be initiated by the hospice, that is, the entity receiving payment for the service. Payments by hospice agencies to physicians or others in a position to refer patients for services furnished under this provision may implicate the Federal anti-kickback statute.
If the beneficiary’s physician is also the medical director or physician employed by a hospice or possesses expertise in the provision of palliative or hospice care, that physician already possesses the expertise necessary to furnish end-of-life services and will have received payment for these services through the use of evaluation and management codes.
For example:
A thoracic surgeon has diagnosed a patient hospitalized in an acute care facility, with end-stage lung cancer with a prognosis of 6 months or less, if the disease runs its normal course. The patient has been informed of this diagnosis. The physician, with the patient’s concurrence, requests a consult by the hospital’s palliative care team. The team meets with the patient, discusses options, evaluates the patient’s pain and symptoms, and makes recommendations including hospice care. Utilization of the evaluation and consultation benefit would be duplicative.
A patient with terminal cervical cancer has been receiving aggressive curative care as an outpatient, which has not been successful. The patient’s physician, nurse and social worker have discussed the possibility of hospice. The patient decides to seek information from a hospice. Utilization of the evaluation and consultation benefit would be appropriate.
Hospice A receives referrals from various physicians and facilities that the patients are certified as having a terminal illness and wish to elect the hospice benefit. Hospice A utilizes the evaluation and consultation benefit for every patient as a preliminary evaluation, prior to the actual election of the benefit. Utilization of the evaluation and consultation benefit would not be appropriate.
Nursing home B contacts Hospice C providing them with a list of patients that can be certified as having a terminal illness. The medical director of Hospice C makes “rounds” on these patients, many of whom are unable to communicate and whose symptoms are being managed well. Utilization of the evaluation and consultation benefit would not be appropriate.
A patient is being treated by a physician for end-stage COPD. The patient is experiencing distressing symptoms, but has not been able to make any definitive decision as to advanced directive decisions. The patient’s physician feels that the expertise of the medical director in Hospice D would be able to provide recommendations as to symptom management and advance directive decisions. The medical director provides the evaluation and consultation services. The patient does not elect the hospice benefit, but is able to make determinations as to his wishes and the physician has recommendations to assist in his provision of care. Utilization of the evaluation and consultation benefit would be appropriate
* be determined to have a terminal illness (which is defined as having a prognosis of 6 months or less if the disease or illness runs its normal course;
* not have made a hospice election, and
* not previously received the pre-election hospice services
Services under this benefit are comprised of:
* evaluating the individual’s need for pain and symptom management;
* counseling the individual regarding hospice and other care options, and may include;
* advising the individual regarding advanced care planning.
The services that comprise this benefit are currently available through other Medicare benefits. For example, evaluation and counseling are often provided by an individual’s
physician as well as by other sources such as discharge planners, case managers, social workers and nonphysician providers.
Therefore, this service may not be reasonable and necessary for all individuals. To the extent that beneficiaries have already received Medicare-covered evaluation and counseling with respect to end-of-life care, the hospice pre-election benefit would seem duplicative. However, if a beneficiary or the beneficiary’s physician deem it necessary to seek the expertise of a hospice medical director or physician employee, this benefit is available to assure that a beneficiary’s end-of-life options for care and pain management are addressed.
Since the decision to utilize this benefit is determined by the beneficiary or the beneficiary’s physician, the evaluation and counseling service may not be initiated by the hospice, that is, the entity receiving payment for the service. Payments by hospice agencies to physicians or others in a position to refer patients for services furnished under this provision may implicate the Federal anti-kickback statute.
If the beneficiary’s physician is also the medical director or physician employed by a hospice or possesses expertise in the provision of palliative or hospice care, that physician already possesses the expertise necessary to furnish end-of-life services and will have received payment for these services through the use of evaluation and management codes.
For example:
A thoracic surgeon has diagnosed a patient hospitalized in an acute care facility, with end-stage lung cancer with a prognosis of 6 months or less, if the disease runs its normal course. The patient has been informed of this diagnosis. The physician, with the patient’s concurrence, requests a consult by the hospital’s palliative care team. The team meets with the patient, discusses options, evaluates the patient’s pain and symptoms, and makes recommendations including hospice care. Utilization of the evaluation and consultation benefit would be duplicative.
A patient with terminal cervical cancer has been receiving aggressive curative care as an outpatient, which has not been successful. The patient’s physician, nurse and social worker have discussed the possibility of hospice. The patient decides to seek information from a hospice. Utilization of the evaluation and consultation benefit would be appropriate.
Hospice A receives referrals from various physicians and facilities that the patients are certified as having a terminal illness and wish to elect the hospice benefit. Hospice A utilizes the evaluation and consultation benefit for every patient as a preliminary evaluation, prior to the actual election of the benefit. Utilization of the evaluation and consultation benefit would not be appropriate.
Nursing home B contacts Hospice C providing them with a list of patients that can be certified as having a terminal illness. The medical director of Hospice C makes “rounds” on these patients, many of whom are unable to communicate and whose symptoms are being managed well. Utilization of the evaluation and consultation benefit would not be appropriate.
A patient is being treated by a physician for end-stage COPD. The patient is experiencing distressing symptoms, but has not been able to make any definitive decision as to advanced directive decisions. The patient’s physician feels that the expertise of the medical director in Hospice D would be able to provide recommendations as to symptom management and advance directive decisions. The medical director provides the evaluation and consultation services. The patient does not elect the hospice benefit, but is able to make determinations as to his wishes and the physician has recommendations to assist in his provision of care. Utilization of the evaluation and consultation benefit would be appropriate
Monday, April 11, 2011
Hospice Contracts with An Entity for Services not Considered Hospice Services
The law governing the provision of Medicare hospice services is found at §1861(dd) of the Act. This law specifies the services covered as hospice care and the conditions a hospice program must meet in order to participate in the Medicare program. One of the conditions a hospice program must meet is that it be “primarily engaged” in providing hospice care and services to terminally ill individuals. The law further clarifies that “terminally ill individuals” are individuals having a “medical prognosis that their life expectancy is six months or less if the illness runs its normal course.” Although the law does not explicitly define its expectations for “primarily engaged,” CMS has interpreted it to mean exactly what it says, that a hospice provider must be primarily engaged in providing hospice care and services (§1861(dd)(2)(A)(i)). “Primarily” does not mean “exclusively.” This requirement does not preclude provision of non-hospice services to terminally ill individuals who are not hospice patients or services to individuals, who are not terminally ill, so long as the primary activity of the hospice is the provision of hospice services to terminally ill individuals.
The CMS recognizes that there may be circumstances in which another health care entity may wish to “purchase” some of the highly specialized staff time or services of a hospice to better meet the needs of its specific patient population. In these cases, the services are not “hospice” services in terms of Medicare payment but become part of the service package of the provider under whose care the patient is. Examples of such circumstances are provided below.
EXAMPLE 1:
A dually eligible Medicare/Medicaid beneficiary enrolled in the Program of All-Inclusive Care for the Elderly (PACE) program for approximately 2 years has been diagnosed with
a life limiting terminal illness with a prognosis of six months or less. In the course of routine assessments, the PACE provider recognizes that the beneficiary would benefit from the specialized services of a pain management specialist or a grief counselor. The PACE provider would then enter into a contractual arrangement with a Medicare certified hospice to purchase these specialized services. The hospice provider would bill the PACE provider for the services, and the PACE provider would in turn pay the hospice provider directly. Neither provider type would be allowed to bill Medicare separately for the contracted services (which in this example are PACE services and included in the PACE provider’s capitated rate). In this example, the PACE provider would maintain a medical record on the patient and the hospice provider would submit any documentation related to the care of the PACE patient to the PACE provider.
EXAMPLE 2:
A Medicare beneficiary is receiving skilled services from a Medicare certified home health agency (HHA). The beneficiary has been diagnosed with a life limiting terminal illness, but chooses to continue curative treatments, thereby rendering him ineligible for the Medicare hospice benefit. The beneficiary is experiencing a period of intractable pain, and the HHA wishes to purchase specialized pain control services from the hospice provider. The HHA would then enter into a contractual arrangement with a Medicare certified hospice to purchase specialized nursing services. The hospice would bill the HHA and the HHA would pay the hospice provider directly. Neither provider type would be allowed to bill Medicare separately for the contracted services (which, in this example, are home health services and therefore included in the HHA’s episode payment). In this example, the HHA would maintain a medical record on the patient, and the hospice submits any documentation related to the pain management to the HHA.
EXAMPLE 3:
A Medicare beneficiary (non-dual eligible) resides in a skilled nursing facility (SNF) and has a diagnosis of Alzheimer’s disease. The beneficiary’s disease process has progressed to a stage in which he/she can no longer ingest food or fluids. The beneficiary’s family has been approached by the SNF regarding the placement of a feeding tube and has been told, “their loved one may not live much longer.” The family is struggling with this concept and has requested assistance from the SNF regarding hospice care and grief counseling. The SNF has provided information about the Medicare hospice benefit to the family, but the patient’s legal representative has made a decision not to elect hospice care at this time. The SNF does not have a trained grief counselor or full-time social worker on staff, but has a business relationship with a local hospice and has requested the services of a pastoral or grief counselor. The SNF and hospice enter into a contractual arrangement for the provision of grief counseling to this beneficiary’s family by a pastoral care counselor. The hospice provider would bill the SNF, and the SNF would pay the hospice provider directly. Neither provider type would be allowed to bill Medicare Part A or B separately for the pastoral care services (which in this example are included in the Medicare’s Resource Utilization Group or RUG payments to the SNF).
The SNF maintains the medical record on this patient and the hospice provider would submit any documentation related to the pastoral care services provided to the SNF.
In all of the examples provided above, the billing and payment for the services are between each of the providers. Medicare must not be billed separately for any of the contracted services referred to in the examples provided above.
The CMS recognizes that there may be circumstances in which another health care entity may wish to “purchase” some of the highly specialized staff time or services of a hospice to better meet the needs of its specific patient population. In these cases, the services are not “hospice” services in terms of Medicare payment but become part of the service package of the provider under whose care the patient is. Examples of such circumstances are provided below.
EXAMPLE 1:
A dually eligible Medicare/Medicaid beneficiary enrolled in the Program of All-Inclusive Care for the Elderly (PACE) program for approximately 2 years has been diagnosed with
a life limiting terminal illness with a prognosis of six months or less. In the course of routine assessments, the PACE provider recognizes that the beneficiary would benefit from the specialized services of a pain management specialist or a grief counselor. The PACE provider would then enter into a contractual arrangement with a Medicare certified hospice to purchase these specialized services. The hospice provider would bill the PACE provider for the services, and the PACE provider would in turn pay the hospice provider directly. Neither provider type would be allowed to bill Medicare separately for the contracted services (which in this example are PACE services and included in the PACE provider’s capitated rate). In this example, the PACE provider would maintain a medical record on the patient and the hospice provider would submit any documentation related to the care of the PACE patient to the PACE provider.
EXAMPLE 2:
A Medicare beneficiary is receiving skilled services from a Medicare certified home health agency (HHA). The beneficiary has been diagnosed with a life limiting terminal illness, but chooses to continue curative treatments, thereby rendering him ineligible for the Medicare hospice benefit. The beneficiary is experiencing a period of intractable pain, and the HHA wishes to purchase specialized pain control services from the hospice provider. The HHA would then enter into a contractual arrangement with a Medicare certified hospice to purchase specialized nursing services. The hospice would bill the HHA and the HHA would pay the hospice provider directly. Neither provider type would be allowed to bill Medicare separately for the contracted services (which, in this example, are home health services and therefore included in the HHA’s episode payment). In this example, the HHA would maintain a medical record on the patient, and the hospice submits any documentation related to the pain management to the HHA.
EXAMPLE 3:
A Medicare beneficiary (non-dual eligible) resides in a skilled nursing facility (SNF) and has a diagnosis of Alzheimer’s disease. The beneficiary’s disease process has progressed to a stage in which he/she can no longer ingest food or fluids. The beneficiary’s family has been approached by the SNF regarding the placement of a feeding tube and has been told, “their loved one may not live much longer.” The family is struggling with this concept and has requested assistance from the SNF regarding hospice care and grief counseling. The SNF has provided information about the Medicare hospice benefit to the family, but the patient’s legal representative has made a decision not to elect hospice care at this time. The SNF does not have a trained grief counselor or full-time social worker on staff, but has a business relationship with a local hospice and has requested the services of a pastoral or grief counselor. The SNF and hospice enter into a contractual arrangement for the provision of grief counseling to this beneficiary’s family by a pastoral care counselor. The hospice provider would bill the SNF, and the SNF would pay the hospice provider directly. Neither provider type would be allowed to bill Medicare Part A or B separately for the pastoral care services (which in this example are included in the Medicare’s Resource Utilization Group or RUG payments to the SNF).
The SNF maintains the medical record on this patient and the hospice provider would submit any documentation related to the pastoral care services provided to the SNF.
In all of the examples provided above, the billing and payment for the services are between each of the providers. Medicare must not be billed separately for any of the contracted services referred to in the examples provided above.
Friday, April 8, 2011
Limitation on Liability of Beneficiaries for Certain Hospice Coverage Denials
Section 1879 of the Act provides protections from liability for charges for certain denied claims to beneficiaries who, acting in good faith, receive inpatient or outpatient services from Medicare Part A providers, or items or services from Medicare Part B suppliers which accept assignment. Likewise, providers and suppliers may also be protected from liability under §1879 of the Act when it is determined that they did not know and could not reasonably have been expected to know that Medicare would deny payment. When the beneficiary is held not liable and the provider also is held to be not liable, payment may be made for a denied claim under §1879, as if the service were covered.
Section 1879(g) of the Act extends limitation on liability protection to a beneficiary enrolled in a hospice when there is a denial of claims due to a determination that the individual is not terminally ill, effective for services furnished on or after August 5, 1997.
When a denial of payment for hospice services is based upon a determination that the beneficiary is not terminally ill, the contractor will apply the usual procedures of the limitation on liability provision.
Section 1879(g) of the Act extends limitation on liability protection to a beneficiary enrolled in a hospice when there is a denial of claims due to a determination that the individual is not terminally ill, effective for services furnished on or after August 5, 1997.
When a denial of payment for hospice services is based upon a determination that the beneficiary is not terminally ill, the contractor will apply the usual procedures of the limitation on liability provision.
Wednesday, April 6, 2011
Short-Term Inpatient Care hospice benefit coverage
Short-term inpatient care may be provided in a participating hospice inpatient unit, or a participating SNF or NF that additionally meets the special hospice standards regarding patient and staffing areas. Medicare payment cannot be made for inpatient hospice care provided in a VA facility to Medicare beneficiaries eligible to receive Veteran’s health services. Services provided in an inpatient setting must conform to the written plan of care. However, dually eligible veterans residing at home in their community may elect the Medicare Hospice Benefit.
Medicare covers two levels of inpatient care: respite care for relief of the patient’s caregivers, and general inpatient care which is for pain control and symptom management.
General inpatient care may be required for procedures necessary for pain control or acute or chronic symptom management that cannot feasibly be provided in other settings. Skilled nursing care may be needed by a patient whose home support has broken down if this breakdown makes it no longer feasible to furnish needed care in the home setting.
General inpatient care under the hospice benefit is not equivalent to a hospital level of care under the Medicare hospital benefit. For example, a brief period of general inpatient care may be needed in some cases when a patient elects the hospice benefit at the end of a covered hospital stay. If a patient in this circumstance continues to need pain control or symptom management, which cannot be feasibly provided in other settings while the patient prepares to receive hospice home care, general inpatient care is appropriate.
Other examples of appropriate general inpatient care include a patient in need of medication adjustment, observation, or other stabilizing treatment, such as psycho-social monitoring, or a patient whose family is unwilling to permit needed care to be furnished in the home.
Inpatient respite care may be furnished to provide respite for the individual’s family or other persons caring for the individual at home.
Note that hospice inpatient care in an SNF or NF serves to prolong current benefit periods for general Medicare hospital and SNF benefits. This could potentially affect patients who revoke the hospice benefit.
If a hospice patient receives general inpatient care for 3 days or more, and elects to revoke hospice, then the 3 day stay (although not equivalent to a hospital level of care) would still qualify the beneficiary for covered SNF services.
Medicare covers two levels of inpatient care: respite care for relief of the patient’s caregivers, and general inpatient care which is for pain control and symptom management.
General inpatient care may be required for procedures necessary for pain control or acute or chronic symptom management that cannot feasibly be provided in other settings. Skilled nursing care may be needed by a patient whose home support has broken down if this breakdown makes it no longer feasible to furnish needed care in the home setting.
General inpatient care under the hospice benefit is not equivalent to a hospital level of care under the Medicare hospital benefit. For example, a brief period of general inpatient care may be needed in some cases when a patient elects the hospice benefit at the end of a covered hospital stay. If a patient in this circumstance continues to need pain control or symptom management, which cannot be feasibly provided in other settings while the patient prepares to receive hospice home care, general inpatient care is appropriate.
Other examples of appropriate general inpatient care include a patient in need of medication adjustment, observation, or other stabilizing treatment, such as psycho-social monitoring, or a patient whose family is unwilling to permit needed care to be furnished in the home.
Inpatient respite care may be furnished to provide respite for the individual’s family or other persons caring for the individual at home.
Note that hospice inpatient care in an SNF or NF serves to prolong current benefit periods for general Medicare hospital and SNF benefits. This could potentially affect patients who revoke the hospice benefit.
If a hospice patient receives general inpatient care for 3 days or more, and elects to revoke hospice, then the 3 day stay (although not equivalent to a hospital level of care) would still qualify the beneficiary for covered SNF services.
Monday, April 4, 2011
Medical Social Services
Medical social services must be provided by a social worker who has at least a bachelor’s degree from a school accredited or approved by the Council on Social Work Education, and who is working under the direction of a physician.
Services of these professionals which may be covered include, but are not limited to:
1. Assessment of the social and emotional factors related to the patient’s illness, need for care, response to treatment and adjustment to care;
2. Assessment of the relationship of the patient’s medical and nursing requirements to the patient’s home situation, financial resources and availability of community resources;
3. Appropriate action to obtain available community resources to assist in resolving the patient’s problem (NOTE: Medicare does not cover the services of a medical social worker to complete or assist in the completion of an application for Medicaid because Federal regulations require the State to provide assistance in completing the application to anyone who chooses to apply for Medicaid.);
4. Counseling services that are required by the patient; and
5. Medical social services furnished to the patient’s family member or caregiver on a short-term basis when the hospice can demonstrate that a brief intervention (that is, two or three visits) by a medical social worker is necessary to remove a clear and direct impediment to the effective treatment of the patient’s medical condition or to the patient’s rate of recovery. To be considered “clear and direct,” the behavior or actions of the family member or caregiver must plainly obstruct, contravene, or prevent the patient’s medical treatment or rate of recovery. Medical social services to address general problems that do not clearly and directly impede treatment or recovery as well as long-term social services furnished to family members, such as ongoing alcohol counseling, are not covered.
Services of these professionals which may be covered include, but are not limited to:
1. Assessment of the social and emotional factors related to the patient’s illness, need for care, response to treatment and adjustment to care;
2. Assessment of the relationship of the patient’s medical and nursing requirements to the patient’s home situation, financial resources and availability of community resources;
3. Appropriate action to obtain available community resources to assist in resolving the patient’s problem (NOTE: Medicare does not cover the services of a medical social worker to complete or assist in the completion of an application for Medicaid because Federal regulations require the State to provide assistance in completing the application to anyone who chooses to apply for Medicaid.);
4. Counseling services that are required by the patient; and
5. Medical social services furnished to the patient’s family member or caregiver on a short-term basis when the hospice can demonstrate that a brief intervention (that is, two or three visits) by a medical social worker is necessary to remove a clear and direct impediment to the effective treatment of the patient’s medical condition or to the patient’s rate of recovery. To be considered “clear and direct,” the behavior or actions of the family member or caregiver must plainly obstruct, contravene, or prevent the patient’s medical treatment or rate of recovery. Medical social services to address general problems that do not clearly and directly impede treatment or recovery as well as long-term social services furnished to family members, such as ongoing alcohol counseling, are not covered.
Core services of Hospice program
Core Services
Nursing services, medical social services, and counseling are core hospice services and must routinely be provided directly by hospice employees. Supplemental services may be contracted in order to meet unusual staffing needs that cannot be anticipated and that occur so infrequently it would not be practical to hire additional staff to fill these needs.
Other services may be provided under arrangement. Arrangements made by a hospice to furnish items or services must be such that receipt of payment by the hospice for the services relieves the beneficiary of liability or any other persons to pay for the services. Whether the services and items are furnished by the hospice itself or by another organization under arrangements made by the hospice, both must agree not to charge the patient for covered services and items and must agree to return money incorrectly collected.
The arrangement agreement includes at least the following:
1. Identification of the services to be provided;
2. A stipulation that services may be provided only with the express authorization of the hospice;
3. The manner in which the contracted services are coordinated, supervised, and evaluated by the hospice;
4. The delineation of the role(s) of the hospice and the contractors in the admission process, patient/family assessment, and the interdisciplinary group care conferences;
5. Requirements for documenting that services are furnished in accordance with the agreement; and
6. The qualifications of the personnel providing the services.
The hospice must maintain professional, financial and administrative responsibility for the services and assure that all staff meet the regulatory qualification requirements.
Nursing services, medical social services, and counseling are core hospice services and must routinely be provided directly by hospice employees. Supplemental services may be contracted in order to meet unusual staffing needs that cannot be anticipated and that occur so infrequently it would not be practical to hire additional staff to fill these needs.
Other services may be provided under arrangement. Arrangements made by a hospice to furnish items or services must be such that receipt of payment by the hospice for the services relieves the beneficiary of liability or any other persons to pay for the services. Whether the services and items are furnished by the hospice itself or by another organization under arrangements made by the hospice, both must agree not to charge the patient for covered services and items and must agree to return money incorrectly collected.
The arrangement agreement includes at least the following:
1. Identification of the services to be provided;
2. A stipulation that services may be provided only with the express authorization of the hospice;
3. The manner in which the contracted services are coordinated, supervised, and evaluated by the hospice;
4. The delineation of the role(s) of the hospice and the contractors in the admission process, patient/family assessment, and the interdisciplinary group care conferences;
5. Requirements for documenting that services are furnished in accordance with the agreement; and
6. The qualifications of the personnel providing the services.
The hospice must maintain professional, financial and administrative responsibility for the services and assure that all staff meet the regulatory qualification requirements.
Sunday, April 3, 2011
Physicians' Services and Nurse Practitioners as Attending Physicians coverage
Physicians' Services
A Physician must perform physicians' services (as defined in 42 CFR 410.20(b)(1)(1)), except that the services of the hospice medical director or the physician member of the interdisciplinary group must be performed by a doctor of medicine or osteopathy. Nurse practitioners may not serve as a medical director or as the physician member of the interdisciplinary group. Nurse practitioners may not bill for medical services other than those described in 40.1.3b.
Attending Physician Services
The attending physician is a doctor of medicine or osteopathy or a nurse practitioner and is identified by the individual, at the time he or she elects to receive hospice care, as having the most significant role in the determination and delivery of the individual’s medical care.
Nurse Practitioners as Attending Physicians
A nurse practitioner is defined as a registered nurse who is permitted to perform such services as legally authorized to perform (in the state in which the services are performed) in accordance with State law (or State regulatory mechanism provided by
State law) and who meets training, education and experience requirements described in 42 CFR 410.75.
If a beneficiary does not have an attending physician or a nurse practitioner who has provided primary care prior to or at the time of the terminal diagnosis, the beneficiary may choose to be served by either a physician or a nurse practitioner who is employed by the hospice. The beneficiary must be provided with a choice of a physician or a nurse practitioner.
Services provided by a nurse practitioner that are medical in nature must be reasonable and necessary, be included in the plan of care and must be services that, in the absence of a nurse practitioner, would be performed by a physician. If the services performed by a nurse practitioner are such that a registered nurse could perform them in the absence of a physician, they are not considered attending physician services and are not separately billable. Services that are duplicative of what the hospice nurse would provide are not separately billable.
Nurse practitioners cannot certify a terminal diagnosis or the prognosis of six months or less, if the illness or disease runs its normal course, or re-certify terminal diagnosis or prognosis. In the event that a beneficiary’s attending physician is a nurse practitioner, the hospice medical director and/or physician designee may certify or re-certify the terminal illness.
A Physician must perform physicians' services (as defined in 42 CFR 410.20(b)(1)(1)), except that the services of the hospice medical director or the physician member of the interdisciplinary group must be performed by a doctor of medicine or osteopathy. Nurse practitioners may not serve as a medical director or as the physician member of the interdisciplinary group. Nurse practitioners may not bill for medical services other than those described in 40.1.3b.
Attending Physician Services
The attending physician is a doctor of medicine or osteopathy or a nurse practitioner and is identified by the individual, at the time he or she elects to receive hospice care, as having the most significant role in the determination and delivery of the individual’s medical care.
Nurse Practitioners as Attending Physicians
A nurse practitioner is defined as a registered nurse who is permitted to perform such services as legally authorized to perform (in the state in which the services are performed) in accordance with State law (or State regulatory mechanism provided by
State law) and who meets training, education and experience requirements described in 42 CFR 410.75.
If a beneficiary does not have an attending physician or a nurse practitioner who has provided primary care prior to or at the time of the terminal diagnosis, the beneficiary may choose to be served by either a physician or a nurse practitioner who is employed by the hospice. The beneficiary must be provided with a choice of a physician or a nurse practitioner.
Services provided by a nurse practitioner that are medical in nature must be reasonable and necessary, be included in the plan of care and must be services that, in the absence of a nurse practitioner, would be performed by a physician. If the services performed by a nurse practitioner are such that a registered nurse could perform them in the absence of a physician, they are not considered attending physician services and are not separately billable. Services that are duplicative of what the hospice nurse would provide are not separately billable.
Nurse practitioners cannot certify a terminal diagnosis or the prognosis of six months or less, if the illness or disease runs its normal course, or re-certify terminal diagnosis or prognosis. In the event that a beneficiary’s attending physician is a nurse practitioner, the hospice medical director and/or physician designee may certify or re-certify the terminal illness.
Saturday, April 2, 2011
Continuous home care - differenent circumstance
The following are used to illustrate circumstances that may qualify as CHC. This list is not all-inclusive nor does it indicate that if a patient presents with similar situations, that it would constitute CHC.
1. Frequent medication adjustment to control symptoms/collapse of family support system
Situation A: The patient has had a central venous catheter inserted to provide access for continuous Fentanyl drip for pain control and for the administration of antiemetic medication to control continuous nausea and vomiting. The nurse spends 2 hours teaching the family members how to administer IV medications. She returns in the evening for 1 hour. The home health aide provides three hours of care. The nurse spends 2 hours phoning physicians, ordering medications, documenting and revising the plan of care.
Determination: Despite 8 hours of service, this does not constitute CHC since 2 of the 8 hours were not activities related to direct patient care.
Situation B: The patient experiences new onset seizures. He continues to have episodes of vomiting. The nurse remains with the patient for 4 hours (10 AM – 2 PM) until the seizures cease. During that time she provides skilled care and family teaching. The patient’s wife states she is unable to provide any more care for her husband. A home health aide is assigned to the patient for monitoring for 24 hours, beginning at 2:00 PM, with a total of 8 hours of direct care in the first day. The nurse returns intermittently for a total of an additional 4 hours to administer medications, assess the patient and to relieve the aide for breaks. The social worker provides 3 hours of services to work with the patient’s wife in identifying alternative methods to care for the patient.
Determination: This qualifies as a continuous home care day. This constitutes a medical crisis, including collapse of family structure. The caregiver has been providing skilled care and the change in the patient’s condition requires the nurse’s interventions. Since there is no overlap in nursing care, 16 hours of care would be computed as CHC. The social worker hours would not be incorporated. If the caregiver had been providing custodial care and his medical crisis resolved within a short time frame, this situation would not have qualified as CHC.
2. Symptom management/rapid deterioration/imminent death Situation A: 77-year-old patient with lung cancer whose caregiver is 80 years old. The caregiver has been caring for this patient for 4 months and is now exhausted and scared. The care provided consists of assisting with bathing, assisting the patient to ambulate, preparing meals, housekeeping and administering oral medications. Since the patient is dyspneic at rest, she requires assistance in all ADLs, which equates to 9 hours of assistance within a 24-hour period.
Determination: This would not qualify, as CHC since there is little nursing care that requires a nurse. The patient would however be a candidate for an inpatient respite level of care.
Situation B: The patient’s condition deteriorates. The patient is now has circumoral cyanosis, respiratory rate of 44 and labored with intermittent episodes of apnea. The nurse performs a complete assessment and teaches the caregiver on methods to make the patient comfortable. The nurse returns twice within the 24 - hour period to assess the patient. She revises the plan of care after conferring with the patient’s attending physician and with the hospice physician. The homemaker and home health aide are sent to assist the caregiver. Within the 24-hour period, the direct care provided by the nurse equates to 3 hours, homemaker with 2 hours, and home health aide of 6 hours.
Determination: Since only 3 of the 11 hours were skilled care requiring the services of a nurse, this would not constitute CHC. In this situation, the care required is not predominantly nursing but are comprised of services provided by a home health aide. In addition, it would not be correct to discount any portion of the home health aide’s hours or to provide these services gratis in order to qualify for the CHC benefit.
Situation C: The next day, the patient’s condition deteriorates further. She has increased periods of apnea and air hunger. In addition she is experiencing continuous vomiting and increasing pain. Her blood pressure is beginning to decrease and her respirations are increasing. The nurse remains at the patient’s bedside for 4 hours while attempting to control her pain and symptoms. The home health aide provides care during one hour of this period. The nurse leaves and the home health aide remains at the bedside for 3 hours. The social worker comes and talks with the caregiver and remains for 1 hour. The nurse returns while the aide leaves. The nurse remains with the patient for 2 hours until she dies. The social worker returns and stays with the caregiver for 1 hour until the mortuary arrives.
Determination: The nurse provided 6 hrs of direct skilled nursing care; the aide provided 4 hours of direct care resulting in a total of 10 hours of registered nurse and home health aide care. Since at least 6 of the 10 hours were direct nursing care, and since nursing care was the predominant service provided during the 10 hours, the care meets the criteria for CHC. In addition, since the nurse and the aide provided direct care for the patient simultaneously, it would be appropriate to bill for each resulting in total of 10 billable hours. The patient received 12 hours of care. The 2 hours for the social worker are not counted towards the CHC hours.
Medicare’s requirements for coverage of CHC are that at least eight hours of primarily nursing care are needed in order to manage an acute medical crisis as necessary to maintain the individual at home. When a hospice determines that a beneficiary meets the requirements for CHC, appropriate documentation must be available to support the requirement that the services provided were reasonable and necessary and were in compliance with an established plan of care in order to meet a particular crisis situation. This would include the appropriate documentation of the situation and the need for continuous care services consistent with the plan of care.
Continuous home care is covered only as necessary to maintain the terminally ill individual at home.
1. Frequent medication adjustment to control symptoms/collapse of family support system
Situation A: The patient has had a central venous catheter inserted to provide access for continuous Fentanyl drip for pain control and for the administration of antiemetic medication to control continuous nausea and vomiting. The nurse spends 2 hours teaching the family members how to administer IV medications. She returns in the evening for 1 hour. The home health aide provides three hours of care. The nurse spends 2 hours phoning physicians, ordering medications, documenting and revising the plan of care.
Determination: Despite 8 hours of service, this does not constitute CHC since 2 of the 8 hours were not activities related to direct patient care.
Situation B: The patient experiences new onset seizures. He continues to have episodes of vomiting. The nurse remains with the patient for 4 hours (10 AM – 2 PM) until the seizures cease. During that time she provides skilled care and family teaching. The patient’s wife states she is unable to provide any more care for her husband. A home health aide is assigned to the patient for monitoring for 24 hours, beginning at 2:00 PM, with a total of 8 hours of direct care in the first day. The nurse returns intermittently for a total of an additional 4 hours to administer medications, assess the patient and to relieve the aide for breaks. The social worker provides 3 hours of services to work with the patient’s wife in identifying alternative methods to care for the patient.
Determination: This qualifies as a continuous home care day. This constitutes a medical crisis, including collapse of family structure. The caregiver has been providing skilled care and the change in the patient’s condition requires the nurse’s interventions. Since there is no overlap in nursing care, 16 hours of care would be computed as CHC. The social worker hours would not be incorporated. If the caregiver had been providing custodial care and his medical crisis resolved within a short time frame, this situation would not have qualified as CHC.
2. Symptom management/rapid deterioration/imminent death Situation A: 77-year-old patient with lung cancer whose caregiver is 80 years old. The caregiver has been caring for this patient for 4 months and is now exhausted and scared. The care provided consists of assisting with bathing, assisting the patient to ambulate, preparing meals, housekeeping and administering oral medications. Since the patient is dyspneic at rest, she requires assistance in all ADLs, which equates to 9 hours of assistance within a 24-hour period.
Determination: This would not qualify, as CHC since there is little nursing care that requires a nurse. The patient would however be a candidate for an inpatient respite level of care.
Situation B: The patient’s condition deteriorates. The patient is now has circumoral cyanosis, respiratory rate of 44 and labored with intermittent episodes of apnea. The nurse performs a complete assessment and teaches the caregiver on methods to make the patient comfortable. The nurse returns twice within the 24 - hour period to assess the patient. She revises the plan of care after conferring with the patient’s attending physician and with the hospice physician. The homemaker and home health aide are sent to assist the caregiver. Within the 24-hour period, the direct care provided by the nurse equates to 3 hours, homemaker with 2 hours, and home health aide of 6 hours.
Determination: Since only 3 of the 11 hours were skilled care requiring the services of a nurse, this would not constitute CHC. In this situation, the care required is not predominantly nursing but are comprised of services provided by a home health aide. In addition, it would not be correct to discount any portion of the home health aide’s hours or to provide these services gratis in order to qualify for the CHC benefit.
Situation C: The next day, the patient’s condition deteriorates further. She has increased periods of apnea and air hunger. In addition she is experiencing continuous vomiting and increasing pain. Her blood pressure is beginning to decrease and her respirations are increasing. The nurse remains at the patient’s bedside for 4 hours while attempting to control her pain and symptoms. The home health aide provides care during one hour of this period. The nurse leaves and the home health aide remains at the bedside for 3 hours. The social worker comes and talks with the caregiver and remains for 1 hour. The nurse returns while the aide leaves. The nurse remains with the patient for 2 hours until she dies. The social worker returns and stays with the caregiver for 1 hour until the mortuary arrives.
Determination: The nurse provided 6 hrs of direct skilled nursing care; the aide provided 4 hours of direct care resulting in a total of 10 hours of registered nurse and home health aide care. Since at least 6 of the 10 hours were direct nursing care, and since nursing care was the predominant service provided during the 10 hours, the care meets the criteria for CHC. In addition, since the nurse and the aide provided direct care for the patient simultaneously, it would be appropriate to bill for each resulting in total of 10 billable hours. The patient received 12 hours of care. The 2 hours for the social worker are not counted towards the CHC hours.
Medicare’s requirements for coverage of CHC are that at least eight hours of primarily nursing care are needed in order to manage an acute medical crisis as necessary to maintain the individual at home. When a hospice determines that a beneficiary meets the requirements for CHC, appropriate documentation must be available to support the requirement that the services provided were reasonable and necessary and were in compliance with an established plan of care in order to meet a particular crisis situation. This would include the appropriate documentation of the situation and the need for continuous care services consistent with the plan of care.
Continuous home care is covered only as necessary to maintain the terminally ill individual at home.
Friday, April 1, 2011
Medicare Nursing Care coverage and benefits
To be covered as nursing services, the services must require the skills of a registered nurse, or a licensed practical (vocational) nurse under the supervision of a registered nurse, must be reasonable and necessary to the treatment of the patient’s illness or injury.
Services provided by a nurse practitioner (NP) who is not the patient’s attending physician, are included under nursing care. This means that, in the absence of a nurse practitioner, a registered nurse (RN) would provide the service. Since the services are nursing, payment is encompassed in the hospice per diem rate and may not be billed separately regardless of whether the services are provided by an NP or an RN. The following are examples of some services that traditionally are provided by a registered nurse, which could also be provided by a nurse practitioner, for which separate payment is not made:
a. A patient with a terminal diagnosis of lung cancer complains of leg pain. In the absence of a nurse practitioner, a registered nurse would assess the patient.
b. Assessment of pain and or symptoms for the determination for the need of medications, other treatments, continuous home care, general inpatient care etc. In the absence of a nurse practitioner, a registered nurse would assess the patient.
c. Administration of medications through intravenous (e.g., PICC, central, etc.), intrathecal or any other means. In the absence of a nurse practitioner, a registered nurse would administer the medication.
d. Family counseling.In the absence of a nurse practitioner, a registered nurse, social worker or counselor would provide this service.
e. Providing a home visit visits for assessment or provision of care to a patient who is not his/her patient. In the absence of the nurse practitioner, the service would be provided by a registered or licensed nurse. Therefore the NP cannot bill separately for the service.
Services provided by a nurse practitioner (NP) who is not the patient’s attending physician, are included under nursing care. This means that, in the absence of a nurse practitioner, a registered nurse (RN) would provide the service. Since the services are nursing, payment is encompassed in the hospice per diem rate and may not be billed separately regardless of whether the services are provided by an NP or an RN. The following are examples of some services that traditionally are provided by a registered nurse, which could also be provided by a nurse practitioner, for which separate payment is not made:
a. A patient with a terminal diagnosis of lung cancer complains of leg pain. In the absence of a nurse practitioner, a registered nurse would assess the patient.
b. Assessment of pain and or symptoms for the determination for the need of medications, other treatments, continuous home care, general inpatient care etc. In the absence of a nurse practitioner, a registered nurse would assess the patient.
c. Administration of medications through intravenous (e.g., PICC, central, etc.), intrathecal or any other means. In the absence of a nurse practitioner, a registered nurse would administer the medication.
d. Family counseling.In the absence of a nurse practitioner, a registered nurse, social worker or counselor would provide this service.
e. Providing a home visit visits for assessment or provision of care to a patient who is not his/her patient. In the absence of the nurse practitioner, the service would be provided by a registered or licensed nurse. Therefore the NP cannot bill separately for the service.
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