Home Health & Hospice Week

If your hospice claims are getting kicked out of the Medicare claims system for having too many line items, chances are you aren't reporting inpatient visits correctly.

The problem: The Centers for Medicare & Medicaid Services requires hospices to report visits by their nurses, home health aides, social workers, physicians, and nurse practitioners. When the patient is residing in a hospice facility, the definition of what constitutes a visit seems to be confusing hospices, said CMS's Randy Throndset in last month's Open Door Forum for home care providers.

Some hospices are submitting claims with too many line items and the claims system is rejecting the claims, one hospice caller noted in the forum that drew 400 attendees.

"Providers are finding it difficult to correctly count visits for patients that are in a facility," agrees billing expert M. Aaron Little with BKD in Springfield, Mo. In an inpatient hospice facility, "there are many times when there is an encounter with the patient."

The solution: Hospices should look to CMS's hospice visit reporting basics to avoid overreporting of visits, Throndset said. Hospices should only report visits that are reasonable and necessary for the palliation and management of the terminal illness.

"Hospices shouldn't record a visit for every time a staff member enters the patient's room," Throndset instructed. Instead, they should consider whether the visit would have been reported if the patient were receiving  routine home care in her private home. If a group of tasks is usually performed in a single visit in a patient's private home, the hospice should count the tasks as a single visit for a patient residing in a facility, he advised.

For example: If an aide enters the room, is interrupted and steps out, then re-enters the room, that shouldn't count as two visits, Throndset explained. Ditto for a nurse who has to leave the room to get medication. "Use your clinical judgment," he exhorted.

"Based on CMS's guidance, not every single encounter would constitute a billable visit," Little counsels. "Ultimately the decision of whether to count an encounter as a visit lies in exercising effective clinical judgment."

Tip: Adhere as closely as possible to CMS's guidance on counting hospice visits that it has issued in program manuals and question-and-answer sets, Little recommends.

Q&As 8900 and 8915, which address counting visits in facilities, might help shed light on the matter. To see all the Q&As about hospice, including multiple items on how to count visits, go to https://questions.cms.hhs.gov, choose "Medicare" in the "Search by Product" box, then choose "Medicare Fee-For-Service Payment" in the next box, then choose "Hospice" in the last box, and hit the "Search" button. Or for a direct link to the FAQs, email editor Rebecca Johnson at rebeccaj@eliresearch.com with "Hospice FAQs Link" in the subject line.

You can also consult CMS's April 2008 transmittal setting out the visit counting rules at www.cms.gov/transmittals/downloads/R1494CP.pdf.

CMS is telling hospices to compare inpatient visits with private home ones, but don't expect to see the same amount of visits in both locations, cautions Samira Beckwith, president and CEO of Hope Hospice and Community Services in Fort Myers, Fla.

"If someone resides in a facility, it most likely means that they need more help than if they were at home," Beckwith points out. "I would not be surprised to see more visits."

But CMS thinks if hospices follow their new guidance, visits numbers will be significantly cut. "A lot of those instances where the number of line items [on claims] is exceeding those that are allowed is because every time that that staff person goes in and out of there, it's being recorded as a separate visit," Throndset told a caller in the forum. "Or they're simply recording the multiple paths that would make up a visit as separate visits."

"We believe that if they follow the guidance ... they won't be exceeding the number," he added.

Concern: CMS may be helping hospices nail down the details of how to count visits, but the new guidance doesn't address a major concern Beckwith has: focusing too much on the medical component of the Medicare hospice benefit. "Hospice developed because of the needs that exist during this very difficult and important chapter of a person's life," Beckwith notes. "Now CMS and others want to go backwards and medicalize hospice."

Visit reporting, which doesn't include visits from pastoral care and other services, also "doesn't allow for an accurate representation of the total care needs," Beckwith worries.