Discharge Status Codes and Occurrence Codes Used on Hospice Claims

Hospices are reminded that CR7473 and CR7478 become effective on January 1, 2012 and have January implementation dates.  These are the CRs that deal with discharge status codes and occurrence codes on hospice claims.  CR 7473 explains the discharge status code to be used when a hospice patient is discharged from hospice and CR7478 tells hospice how to process a discharge from the Medicare hospice benefit when the face-to-face encounter is not completed timely. 

Hospices are to use occurrence code 42 when submitting claims that end the beneficiary’s election period not to be confused with discharge status code 42 that indicates to CMS the patient has expired. 

Clarification of How Hospice Discharges Need to be Reflected on Claims

CR 7473 revises Chapter 11 of the Medicare Claims Processing Manual to provide more detailed instruction related to hospice coding on claims, with the most notable change in instruction occurring in the coding of hospice discharges.  The full CR can be accessed at https://www.cms.gov/transmittals/downloads/R2258CP.pdf.  Revisions occurred in the following sections of Chapter 11:

• 10.1 Hospice Pre-Election Evaluation and Counseling Services - clarified that this service can only be billed once per beneficiary.
• 30.3 Data Required on the Institutional Claim - clarified that hospices must submit a Notice of Election (NOE) before submitting a claim.
• 30.3 Data Required on the Institutional Claim - Patient Discharge Status. This section has the most substantive changes (summarized below).
• 30.4 Claims From Medicare Advantage Organizations.
• 90 Frequency of Billing and Same Day Billing – Medicare put in writing more clear language that hospices are to bill monthly and how it is to be done.

Further information on the most significantly changed section, 30.3, is provided below.

30.3 Data Required on the Institutional Claim - Patient Discharge Status

Discharge status code of 20 is not to be used for hospices.  When the patient discharges due to death, hospices are to use codes 40, 41, or 42.  These codes are based on the location of the patient's death. The manual lists three reasons for discharge from hospice care:

1.             The beneficiary moves out of the hospice’s service area or transfers to another hospice.

2.             The hospice determines that the beneficiary is no longer terminally ill.

3.             The hospice determines the beneficiary meets their internal policy regarding discharge for cause.

Each of these discharge situations requires different coding on Medicare claims. Under #1, if the beneficiary moves out of the service area without a transfer, the CR directs the hospice to use the discharge status code that best describes the beneficiary's situation.  The hospice is not to use discharge status code 42 as it indicates the patient has expired. In the case of a discharge when the beneficiary moves out of the hospice’s service area and transfers to another hospice, the hospice uses discharge status code 50 or 51, depending on whether the beneficiary is transferring to home hospice or hospice in a medical facility. The hospice does not report discharge status code 42 on their claim.

Under #2, in the case of a discharge when the hospice determines the beneficiary is no longer terminally ill, the hospice uses the approved discharge status code that best describes the beneficiary’s situation. The hospice also reports occurrence code 42 on their claim and the date of their determination. This discharge claim will terminate the beneficiary’s current hospice benefit period as of the occurrence code 42 date. This coding may also be used if the beneficiary has chosen to revoke their hospice election. The beneficiary may re-elect the hospice benefit if they are certified as terminally ill and eligible for the benefit again in the future.  

Under #3, in the case of a discharge for cause, the hospice uses the approved discharge status code that best describes the beneficiary’s situation. The hospice does not report occurrence code 42 on their claim. Instead, the hospice reports condition code H2 to indicate a discharge for cause. The effect of this discharge claim on the beneficiary’s current hospice benefit period depends on the discharge status. 

Also, in this CR CMS clarified how to record visits on the claim.  For the service date detail on the claim, for service visits that begin in one calendar day and span into the next calendar day hospices are to report one visit using the date the visit ended as the service date.

Click here https://www.cms.gov/MLNMattersArticles/downloads/SE0801.pdf  for details on the patient discharge status codes that are to be used. Hospices will want to retain this information for future reference. 

Clarification of How to Process Claims When the Face to Face Does Not Occur Timely

CR7478 deals with this issue.  Essentially, it delineates the claims processing guidance previously provided by CMS through Q&As.  

“When a discharge from the Medicare hospice benefit occurs due to failure to perform a required face-to-face encounter timely, the claim should include the most appropriate patient discharge status code and occurrence code 42, as described in the Medicare Claims Processing Manual, Pub. 100-04, Chapter 11, Section 30.3.”   The occurrence code 42 indicates to CMS that the benefit period is ending. 

“The hospice can re-admit the patient to the Medicare hospice benefit once the required encounter occurs, provided the patient continues to meet all of the eligibility requirements and the patient (or representative) files an election statement in accordance with CMS regulations.

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

Occurrence span code 77 does not apply to the above described situations when the face-to-face encounter has not occurred timely.

While the face-to-face encounter itself must occur no more than 30 calendar days prior to the start of the third benefit period recertification and each subsequent recertification, its accompanying attestation must be completed before the claim is submitted.”

Note that CR7478 references Section 30.3 of the Claims Processing Manual, which as of this writing has not yet been updated on the CMS website to reflect the changes to it made by CR7473. 

Hospice Discharge Planning Requirements

The topic of discharge in hospice has generated much discussion, and CMS released a Question and Answer (Q&A) on the subject. The focus of the Q&A is on the amount of time a hospice has for discharge planning. CMS has indicated that each case is unique, and there is not a specific timeframe in which hospices have to conduct discharge planning. Rather, the hospice is to be prepared for the possibility of a patient’s discharge and is to proceed with that discharge in a timeframe that is based on the patient’s situation and needs, not the benefit period dates. The typical scenario where this question comes up is when the hospice realizes that a patient’s condition may not warrant recertification. CMS expects the hospice to proceed with the necessary discharge planning and discharge the patient, regardless of the benefit period dates. This may mean that the patient is discharged not long after being admitted to hospice.  When the hospice recognizes the need for discharge closer to the end of the benefit period, and it takes longer to complete the discharge process than there are days remaining in the benefit period, CMS expects the hospice “…to continue to care for the patient at its own expense until required discharge planning is complete.” The Q&A is copied below.

Q. We have a hospice patient who is no longer considered terminally ill. Can the patient remain on the hospice benefit while we complete the discharge planning process?

A. Once it is determined that the patient is no longer terminally ill, the patient is no longer eligible to receive the Medicare hospice benefit. In such instances, the hospice must discharge the patient from the Medicare hospice benefit. Our regulations at 418.26(d) require that the hospice have in place a process "that takes into account the prospect that a patient's condition might stabilize or otherwise change such that the patient cannot continue to be certified as terminally ill." When a hospice has not properly planned for a discharge, we would expect the hospice to continue to care for the patient at its own expense until required discharge planning is complete.

The Hospice Association of America (HAA), a NAHC affiliate, suggests that all hospices have a process whereby the IDG assesses a patient’s eligibility on an ongoing basis; discharge should never be a surprise to the patient/family nor the hospice staff.