Hospice Billing

How to Bill When the Hospice Face-to-Face is Late from a Previous Benefit Period

Background

CMS requires that a hospice physician or hospice nurse practitioner must have a FTF encounter with each hospice patient prior to the beginning of the patient’s third benefit period and prior to each subsequent benefit period. Failure to meet the FTF encounter requirements specified in CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 9, Section 20.1 results in a failure by the hospice agency to meet the patient’s recertification of terminal illness eligibility requirement and the patient would cease to be eligible for the benefit.

If the required FTF encounter is not timely, the hospice agency is unable to recertify the patient as terminally ill, and the patient would then cease to be eligible for the Medicare hospice benefit. In such instances, the hospice agency must discharge the patient from the Medicare hospice benefit as he or she is no longer considered terminally ill as per Medicare regulations.

Where the only reason the patient ceases to be eligible for the Medicare hospice benefit is the hospice’s failure to meet the FTF requirement, CMS would expect the hospice agency to continue to care for the patient at its own expense until the required encounter occurs, enabling the hospice to re-establish Medicare eligibility.

Timeliness of the Face-to-Face

A timely FTF encounter occurs prior to, but no more than 30 calendar days prior to, the third benefit period recertification, and every benefit period recertification thereafter. A FTF encounter may occur on the first day of the benefit period and still be considered timely.

Scenario

  • The patient is in a third or later benefit period.
  • A FTF was due on 9/26/20XX.
  • The FTF was done but was not within the requirements to be timely. (Therefore, a timely FTF was not obtained for the certification period starting on 9/26/20XX).
  • The next certification period starts on 11/25/20XX.
  • A timely FTF was completed for the benefit period starting on 11/25/20XX.
  • The hospice agency noted that a timely FTF was not completed for the prior benefit period.

It is imperative to remember the Medicare regulations require the patient be promptly discharged when the FTF is missed and may be readmitted once the FTF has been completed. In this scenario the hospice obtained the physician certification of terminal illness and beneficiary election notice and fulfilled all other program requirements in order to admit the patient on 11/26/20XX when the error was noted.

Billing Considerations

The hospice will only be able to bill Medicare through 9/25/20XX, which is the last coverable day of the prior benefit period. The month of October is not billable to Medicare since the patient did not meet eligibility requirements. For the month of November, Medicare cannot be billed for any days prior to the new admission date of 11/26/20XX, when the FTF was completed and the patient was readmitted.

The use of occurrence code 77 is not appropriate when the FTF is late. Submitting an 8XB in this circumstance is not required. When the FTF is late, Medicare cannot be billed for days that the patient did not meet eligibility. Please follow the billing instructions below.

Instructions

  1. Submit a NOE for the new admission on 11/26/20XX. The NOE will RTP, however this will create a trail to show the NOE was submitted timely.
  2. Cancel the October claim.
  3. Adjust the September claim to indicate that it is a final claim and ends on 9/25/20XX.
  4. No claims will be submitted to Medicare during the time frame the beneficiary was ineligible for the Medicare hospice benefit.
  5. Once the FTF has been completed and the patient readmitted, resubmit the NOE to establish a new benefit period
  6. Once the NOE has processed and finalized the November claim for the new admission can be submitted.

Note: The claim(s) for the late NOE will have to be filed with coding for a late filed NOE with an exceptional circumstance.

Revised 6/11/2024