Advanced Search

Home Health & Hospice Week

Hospice:

Kick Hospice Consult Kickbacks To The Curb

Published on Mon Mar 07, 2005

CMS issues instructions on hospice pre-election evaluation and counseling services.

If your hospice medical director isn't furnishing evaluation and counseling services under new billing code G0337, you're missing out on a potential source of revenue. But you'll have to mind your P's and Q's when using the new benefit.
 
Congress mandated the service in the Medicare Modernization Act of 2003 and it took effect Jan. 1 this year (see Eli's HCW, Vol. XIII, No. 40, p. 316). "It's a good thing," praises attorney Connie Raffa with Arent Fox in New York City. "People don't know about end-of-life care," and this service allows them to find out about it from an expert without committing to the hospice benefit, which requires them to forego curative treatment for their terminal illness.
 
In the wake of the Terri Schiavo case, Medicare beneficiaries are seeking end-of-life care information more than ever, Raffa notes.
 
But that doesn't mean the new service is easy to bill for. "There are lots of different hoops to jump through to do it right," Raffa acknowledges.
 
In a Medlearn Matters article on the topic revised March 25, the Centers for Medicare & Medicaid Services notes these issues regarding the service:

 

  • Six-month prognosis. Like the hospice benefit, the pre-election evaluation and counseling requires a six-month prognosis, CMS notes. But unlike the hospice benefit, a physician doesn't have to certify the prognosis. The referring physician must include a "determination of the terminal diagnosis," but actual "certification of the terminal diagnosis is not required," CMS clarifies.
     
    "The standard to 'determine' the terminal status is less stringent than certification," notes Burtons-ville, MD-based health care attorney Elizabeth Hogue. "This language is consistent with the whole purpose of the benefit, which is to evaluate patients' appropriateness for hospice care."
     
    But even this relaxed standard is too strict a requirement, argues John Mahoney, principal of the Summit Business Group in Penfield, NJ. "That a person be terminally ill with a prognosis of six months or less to obtain this consult benefit is an absurd restriction," criticizes Mahoney, former president of the National Hospice Organization.
     
    "In just about any other context any physician can ask another physician for a consult," Mahoney tells Eli. "But under this rule, in order for a physician or beneficiary to ask a most knowledgeable resource (i.e., a hospice physician) for a consult ... the patient not only has to be very sick, they have to be dying, and dying very soon."

     

  • Kickbacks. "Payments by hospice agencies to physicians or others in a position to refer patients for services furnished under this provision may implicate the Federal anti-kickback statute," CMS warns in the article. A medical director or other physician must be employed by the hospice to furnish this service, which the hospice bills the regional home health intermediary for, the article spells out.
     
    When physicians are full-time employees of the hospice and receive no extra payment for furnishing the eval visits, kickback problems should be few. Directly employed physicians generally fall into the employee safe harbor of the anti-kickback statute, Hogue notes.
     
    But problems may arise if the medical director or physician furnishing the service is a part-time employee and receives extra payments for furnishing the visits. Hospices often employ medical directors who work part time, Raffa notes.
     
    And in some markets, competition for medical directors is fierce, Mahoney says. That could lead hospices to mistakenly offer perks that would violate the anti-kickback statute (see box, next page, for ways to avoid kickback problems).

     

  • Duplication. If your medical director is already the patient's attending physician, the hospice can't bill for G0337, CMS instructs. Instead, the physician must obtain payment for her services through evaluation and management codes billed to her Part B carrier.

    The warning against kickbacks and duplication suggests that CMS is afraid hospices will overuse the benefit, Mahoney says. He deems that prospect unlikely, especially given that the code carries only a $54 reimbursement rate.
     
    "Considering how much time it is likely to take a physician to conduct such a consult and write up the note, the payment is not particularly generous," he points out.
     
    But that won't keep the feds from scrutinizing the eval and counseling claims closely if they are worried about overutilization. And because of the varied requirements for the service, hospices are likely to be confused about how to use it, especially at the beginning, Mahoney adds. 
     
    Editor's Note: The Medlearn Matters article is at     www.cms.hhs.gov/medlearn/matters/mmarticles/2005/MM3585.pdf.

    • Other Articles in this issue of

    Home Health & Hospice Week

    View All