The Medicare Hospice Benefit: Effects on Other Provider Types

Table of Contents

• The Medicare Hospice Benefit: Effects on Other Provider Types
• What is Hospice Care
• Providing Services Related to the Terminal Condition
• Providing Services Unrelated to the Terminal Condition
  • CC (UB-04 FL 18-28)
  • Modifier (UB-04 FL 44) (CMS-1500 Item 24D)
• Physician Service and the Medicare Hospice Benefit
  • Modifiers (UB-04 FL 44) (CMS-1500 Item 24D)
• MA Plans and the Medicare Hospice Benefit
• Skilled Nursing Facilities/Nursing Facilities and the Medicare Hospice Benefit
• DME and the Medicare Hospice Benefit
• Related Content

[Return to Top]

The Medicare Hospice Benefit: Effects on Other Provider Types

Hospice care is a benefit under the hospital insurance program. To be eligible to elect hospice care under Medicare, an individual must be entitled to Part A of Medicare and be certified as being terminally ill. An individual is considered to be terminally ill if the medical prognosis is that the individual’s life expectancy is six months or less if the illness runs its normal course.

An individual (or his authorized representative) must elect hospice care to receive it. An individual may elect to receive Medicare coverage for an unlimited number of election periods of hospice care. The periods consist of two, 90-day periods, and an unlimited number of 60-day periods. If the individual (or authorized representative) elects to receive hospice care, he or she must file an election statement with a particular hospice. Once the initial election is processed, the CWF maintains the beneficiary in hospice status until death or until an election termination is received.

An individual must waive all rights to Medicare payments for the duration of the election/revocation of hospice care for the following services:

• Hospice care provided by a hospice other than the hospice designated by the individual (unless provided under arrangements made by the designated hospice); and
• Any Medicare services that are related to the treatment of the terminal condition for which hospice care was elected or a related condition or services that are equivalent to hospice care, except for services provided by:

1. The designated hospice (either directly or under arrangement);
2. Another hospice under arrangements made by the designated hospice; or
3. The individual’s attending physician, who may be a NP if that physician or nurse practitioner is not an employee of the designated hospice or receiving compensation from the hospice for those services.

Medicare services for a condition completely unrelated to the terminal condition for which hospice was elected remain available to the patient if he or she is eligible for such care.

[Return to Top]

What is Hospice Care

Hospice care provides care and support for the terminally ill focusing on comfort, not on curing an illness. A specially trained team of professionals and caregivers provide hospice care for the “whole person,” including his or her physical, emotional, social, and spiritual needs as well as support to family members caring for a terminally ill individual.

Medicare covers the following for the terminal illness and related conditions while a patient is in the Medicare hospice benefit:

• Doctor services
• Nursing care
• Medical equipment (such as wheelchairs or walkers)
• Medical supplies (such as bandages and catheters)
• Drugs for symptom control or pain relief (patients may need to pay a small copayment)
• Hospice aide and homemaker services
• Physical and occupational therapy
• Speech-language pathology services
• Social worker services
• Dietary counseling
• Spiritual counseling
• Grief and loss counseling for the patient and their family
• Short-term inpatient care (for pain and symptom management)
• Short-term respite care (patients may need to pay a small copayment)
• Any other Medicare-covered services needed to manage pain and other symptoms, as recommended by the hospice team

When a beneficiary chooses hospice care, they have decided that they no longer want care to cure their terminal illness. Medicare will not cover any of the following once a beneficiary elects the Medicare hospice benefit:

• Treatment intended to cure the terminal illness (the beneficiary always has the right to stop hospice care at any time by revoking the benefit)
• Prescription drugs to cure the terminal illness (rather than for symptom control or pain relief)
• Care from any hospice provider that wasn’t set up by the hospice medical team
• Room and board (Medicare does not cover room and board. However, if the hospice team determines that the beneficiary needs short-term inpatient or respite care services that they arrange, Medicare will cover the stay in the facility. Beneficiaries may have to pay a small copayment for the respite stay.)
• Care in an emergency room, inpatient facility care, or ambulance transportation, unless it’s either arranged by your hospice team or is unrelated to your terminal illness. (Note: Beneficiaries must contact their hospice team before they get any of these services or the beneficiary might have to pay the entire cost.)

A hospice beneficiary must get hospice care from the hospice provider they chose. All care that they get for their terminal illness must be given by or arranged by the hospice team. Beneficiaries cannot get the same type of hospice care from a different provider, unless they change their hospice provider (allowed once per benefit period). However, the beneficiary can still see their regular doctor if they have chosen him or her to be the attending medical professional who helps supervise their hospice care.

[Return to Top]

Providing Services Related to the Terminal Condition

Any services related to the terminal condition must be arranged through the hospice that is responsible for the patient. All hospice-related services must be provided under arrangement with the hospice; therefore, open communication with the hospice and the other provider of service is extremely important. The hospice is not responsible for services provided outside of the plan of care.

For the duration of an election of hospice care, an individual waives all rights to Medicare payments for any Medicare services that are related to the treatment of the terminal condition for which hospice care was elected, or a related condition. If a beneficiary seeks services for the terminal illness or related conditions without the hospice arranging it, then the beneficiary is liable for the cost of the services. Patient liability in this situation applies for any services including, but not limited to, labs, diagnostics, inpatient stays, and emergency room visits.

[Return to Top]

Providing Services Unrelated to the Terminal Condition

It is important to communicate with the hospice to discuss the plan of care as this will help in determining if your services are related or unrelated to the terminal condition. Any services unrelated to the terminal condition must be billed with specific coding to identify that the services are not related to the terminal condition. Which code(s) are used will depend on the way you submit your claims to Medicare. The codes listed below are only those most frequently applicable on claims when hospice is involved. For a complete list of codes, see the NUBC manual. The NUBC maintains the UB-04 data element specifications and revenue code tables. They may be contacted for subscription to the UB-04 at the NUBC website.

Providers who submit claims on UB-04s will report the condition code below to indicate that the services being billed are not related to the terminal condition.

[Return to Top]

CC (UB-04 FL 18-28)

Providers and suppliers who submit claims on the CMS-1500 claim form will report the modifier below to indicate that the services being billed are not related to the terminal condition.

[Return to Top]

Modifier (UB-04 FL 44) (CMS-1500 Item 24D)

[Return to Top]

Physician Service and the Medicare Hospice Benefit

Payment for physician services provided in conjunction with the hospice benefit is made based on the type of service performed. Professional services provided by a physician who is employed, contracted or a volunteer of the hospice are separately billable by the hospice.

Payment for physicians or nurse practitioners serving as the attending physician, who provide direct patient care services and who are hospice employees or working under arrangement with the hospice are billed by the hospice.

Professional services related to the hospice patient’s terminal condition that were furnished by an independent attending physician, who may be a nurse practitioner, are billed to the Medicare contractor through Medicare Part B.

Payment for physicians’ administrative and general supervisory activities is included in the hospice payment rates and is not separately billable. These activities include participating in the establishment, review and updating of plans of care, supervising care and services and establishing governing policies.

Physicians (or nurse practitioners who are designated as the attending physician) report the modifier(s) below when billing for services provided to a patient in the Medicare hospice benefit.

[Return to Top]

Modifiers (UB-04 FL 44) (CMS-1500 Item 24D)

[Return to Top]

MA Plans and the Medicare Hospice Benefit

When a MA plan enrolled beneficiary elects the Medicare hospice benefit, all payments revert to the FFS Medicare contractor. All Medicare-covered services provided while in the Medicare hospice benefit are covered under Original Medicare, this includes any Medicare-covered services for conditions unrelated to the terminal illness. The MA plan will continue to cover extra services not covered by Original Medicare (such as dental and vision benefits) if these services are part of the beneficiary’s MA plan package. All Medicare coverable claims will continue to be billed to the FFS contractor as if the beneficiary were a fee-for-service beneficiary until the first day of the month following the month in which hospice was revoked.

For example, an MA-enrolled individual elects the Medicare hospice benefit on August 10^th and revokes the hospice benefit on September 6^th.Beginning with the date of admission to hospice (August 10^th), all Medicare-coverable claims must be billed to the FFS contractor. Claims will continue to go through the FFS contractor until September 30^th (since the revocation occurred in September). Claims will then be submitted to the MA plan beginning on October 1^st.

More information on MA plans as they relate to hospice can be found in the CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 9 Coverage of Hospice Services Under Hospital Insurance, Section 20.2

[Return to Top]

Skilled Nursing Facilities/Nursing Facilities and the Medicare Hospice Benefit

A Medicare beneficiary who resides in a SNF or NF may elect the Medicare hospice benefit if:

• The residential care is paid for by the beneficiary; or
• The beneficiary is eligible for Medicaid and the facility is being reimbursed for the beneficiary’s care by Medicaid, and
• The hospice and the facility have a written agreement under which the hospice takes full responsibility for the professional management of the individual’s hospice care and the facility agrees to provide room and board to the individual.

Note: A beneficiary could be in a SNF under the SNF benefit for a condition unrelated to the terminal condition and simultaneously be receiving hospice for the terminal condition. The hospice would be responsible for the care provided related to the terminal condition.

The hospice is not responsible for SNF/NF requirements that may be in effect by the SNF/NF for any residents within their facility.

[Return to Top]

DME and the Medicare Hospice Benefit

Once the hospice benefit is elected, the hospice is responsible for providing any and all services indicated in the plan of care as necessary for the palliation and management of the terminal illness and related conditions. DME suppliers and the beneficiary should speak to the hospice to determine if the supplies/equipment are part of the hospice plan of care and related to the terminal illness when ordering routine or nonroutine medical supplies (i.e., catheters, tracheostomy care kits, ostomy supplies, etc.) or durable medical equipment (i.e., wheelchairs, hospital beds, walkers, etc.), prosthetics, and orthotic devices.

Note: Any equipment or supplies that are part of the hospice plan of care are handled by the hospice agency and all other equipment or supplies not part of the plan of would be handled by the supplier for DMEPOS.

[Return to Top]

Related Content

• CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 9 Coverage of Hospice Services Under Hospital Insurance
• CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 25 Completing and Processing the Form CMS-1450 Data Set.
• CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 26 Completing and Processing Form CMS-1500 Data Set.