Reimbursement for Services

COVERAGE FOR HOSPICE AND PALLIATIVE CARE SERVICES

Hospice care and palliative medicine services are routinely covered by Medicare and Medicaid. These services are also covered by most employer-provided health care plans, although the specific coverage will vary by plan. Hospice & Palliative Care Charlotte Region accepts Medicare, Medicaid, and commercial insurance payment for services rendered. Please check with your health care plan administrator to learn more about your own coverage for hospice care and palliative medicine services. For patients who may lack health care coverage, Hospice & Palliative Care Charlotte Region will provide services based on a sliding fee scale. Through charitable community support, HPCCR may offer a subsidy for those patients who lack the financial resources to pay for our services.

Hospice& Palliative Care Charlotte Region will provide each patient with a written explanation of benefits received from the insurance carrier within 30 days from the start of care. This explanation will detail the policy limitations, deductible, out of pocket costs, and specific benefit limitations applicable to the patient's plan. Financial counselors are available to assist you or your loved one with any questions you may have regarding your insurance coverage for hospice care or palliative medicine services. A financial counselor may be reached during business hours, 8:30am until 5pm, Monday through Friday.

PHYSICIAN BILLING GUIDELINES FOR HOSPICE MEDICARE BENEFIT

The information contained in this document is intended to serve as a guide only; it is not intended to be viewed as billing advice. Physicians should still refer to the CMS Medicare Claims Processing Manual (Publication 100-4, Medicare Claims Processing, Chapter 11) for specific Medicare guidelines and instructions related to billing.

The following information is for patients accessing the Hospice Medicare Benefit (HMB)

Physician Type	Service	Source	Who Bills	Modifier Code
Attending	Professional	Medicare Part B	Physician bills Medicare B carrier	Use "GV" for services related to terminal illness
Attending	Technical	Hospice daily rate	Physician bills HPCCR	N/A
Attending	Administrative	Medicare Part B^1,2,3,4	Physician bills Medicare B carrier	G0182⁵
Consulting	Professional	Medicare Part A	Physician bills HPCCR⁶	N/A
Consulting	Technical	Hospice daily rate	Physician bills HPCCR⁶	N/A

¹ Payment is available for one physician per month involving 30 minutes of the physician's time per month.

² Must not submit the claim until after the end of the month in which the service is performed.

³ Must report care planning only once per calendar month.

⁴ Use CPT code 99377 for 15-29 minutes per month; use code 99387 for 30 minutes or more (reimbursement not increased for documenting more than 30 minutes)

⁵ HCPCS code G0182 must be the first and last date during which documented care planning services were actually provided during the calendar month (not the first and last calendar date of the month in which the claim in submitted)

⁶The physician bills Hospice & Palliative Care Charlotte Region who then bills Medicare Part A for both professional and technical services.

Billing Definitions

The attending physician is the physician designated by the patient to have the most significant role in the determinations and delivery of the patient's medical care while under the Hospice Medicare Benefit during the election process. The primary physician, as indicated on the Notice of Election (NOE), is the attending physician.

The consulting physician is the physician, other than the attending, who provides direct patient care at the request of the hospice interdisciplinary team, for a condition related to the terminal illness.

*The physician must have a contract with Hospice & Palliative Care Charlotte Region

The covering physician is the physician who has reciprocal billing arrangements with another physician or another member of the physician's group under the following guidelines:

The attending physician is unavailable to provide the services.

The patient sought the visit with the attending physician.

The covering physician does not provide services tot he patient for a continuous period of longer than 60 days.

*Bill according to Attending Physician guidelines, but use Q5 in item 24D of the HCFA 1500.

Professional services are the actual procedures performed by the physican as designated by the appropriate CPT-4 code. Examples include patient visits, procedures, physician interpretation of x-rays, CT scan, MRI or physician interpretation of a laboratory test.

*Look up the code in the CPT-4 Code book to ensure that the service was a professional service and not technical or administrative.

Technical services include labs, x-rays, and any other non-professional services performed by the physician or other health care professional required for the management of the terminal illness.

Administrative services include participating in the establishment, review, and updating of the plan of care, supervising care and services, and establishing governing policies.

Bill Medicare Part B, Code G0182.

Other General Information

Any physician, attending or consultant, who provides services to hospice patients not related to the terminal illness should bill as though the patient were not on hospice.

*Utilize Modifier code GW for services not related to the terminal illness

Complexity based E&M coding may be used for any of your patient visits using the standard E&M guidelines which are based on the complexity of the history, exam and problem solving.

Time based coding: if more than half of your time was spent in counseling and/or coordination of care, you may bill based on the time guidelines, regardless of the complexity. Please refer to CPT code book for specific coding guidelines.

Prolonged service codes may be used for a visit that lasts more than 30 minutes longer than the E&M based suggested times.
*99356/99354: first additional 30-74 minutes
*99357/99355: each additional 30 minutes

Please direct any invoice inquiries to Diana Whitney or call 704.375.0100.

The Hospice Payment System Fact Sheet, which offers providers information about the Medicare hospice benefit, is now available from the Centers for Medicare & Medicaid Services Medicare Learning Network in downloadable format at http://www.cms.hhs.gov/MLNProducts/downloads/hospice_pay_sys_fs.pdf.