RG – Billing and Reimbursement
Hospices must bill for their Medicare beneficiaries on a monthly basis. Monthly billing must conform to a calendar month (i.e., limit services to those in the same calendar month if services began mid-month) rather than a 30 day period which could span two calendar months. Claims must include only services provided in the calendar month, even if it's less than a month billed.
Specific data are required on claims, including the location of care, level of care, increments of care by discipline, medications, dates of services and charges. Claims data are used by CMS better understand what services and medications are provided and determine reimbursement rates.
All visits related to the palliation and management of the terminal illness or related conditions must be reported. Hospices report social worker phone calls and all visits performed by hospice staff in 15 minute increments using the revenue codes and associated HCPCS. This includes visits by hospice nurses, aides, social workers, physical therapists, occupational therapists, and speech-language pathologists. Spiritual care counselors/chaplains are not reported as there is no revenue code for this discipline.
A general explanation of billing areas is provided below. Refer to the Medicare Claims Processing Manual Chapter 11 - Processing Hospice Claims and the appropriate MAC provides the detailed processes and references.
Beginning January 1, 2021, the CMS Innovation Center (CMMI) established a model where Medicare Advantage Organizations (MAOs) can add hospice services (carve in) to the MAO’s plan benefits through the Hospice Benefit Component of the Value-Based Insurance Design Model (VBID). There are different billing requirements when a patient elects hospice and is enrolled in a MA plan participating in VBID. CMMI has more information on the Hospice Benefit Component of VBID, including a description of the benefit and a list of MAOs participating for CY 2021 and CY 2022.
Notice of Election (NOE)
When a Medicare beneficiary elects hospice services, hospices must file a completed Notice of Election (NOE) within 5 calendar days after the hospice admission date. A timely-filed NOE is a NOE that is submitted to the Medicare Administrative Contractor (MAC) and accepted by the MAC within 5 calendar days after the hospice admission date. Posting to the Common Working File (CWF) may not occur within that same time frame. The date of posting to the CWF is not a reflection of whether the NOE is considered filed timely. In instances where a NOE is not filed timely, Medicare will not cover and pay for the days of hospice care from the hospice admission date to the date the NOE is submitted to, and accepted by, the MAC. If a hospice fails to file a timely NOE, it may request an exception which, if approved, waives the consequences of filing a NOE late.
Note: Even if the beneficiary has elected Medicare as a secondary payer, a timely NOE is still required within the 5 day timeframe.
Start of Care
Patients under skilled days in a skilled nursing facility (SNF) who elect hospice cannot receive skilled days at the same time as hospice services, except under very limited circumstances where the skilled care days are completely unrelated to the terminal and related conditions. Otherwise, the effective date of election would need to be after the skilled days have ceased.
Patients who are receiving Medicare home health services and dialysis (for end-stage renal disease) cannot elect hospice care at the same time as these services, except under very limited circumstances where the home health services are completely unrelated to the terminal and related conditions. Otherwise, the effective date of election would need to be after home health has ceased.
Location of Care (Q Codes)
Hospices must report a HCPCS code (known as Q Codes) along with each level of care revenue code to identify the type of service location where that level of care was provided to the hospice beneficiary receiving care under the Medicare Hospice Benefit.
Notice of Termination/Revocation (NOTR)
NOTR is used when the hospice beneficiary is discharged alive (no longer eligible or leaves the service area or for cause) from the hospice or revokes the election of hospice services. An NOTR should not be used when a patient is transferred to another hospice. A timely- filed NOTR is a NOTR that is submitted to the MAC and accepted by the MAC within 5 calendar days after the effective date of discharge or revocation.
Transfers
In cases where one hospice transfers the beneficiary to another hospice (with a different number) that admits the beneficiary on the same day, each hospice is permitted to bill, and each will be reimbursed at the appropriate level of care for its respective day of discharge or admission. In order for the receiving hospice to begin billing, the sending hospice must complete their billing for services, due to sequential billing requirements. The date of the transfer is indicated by the beneficiary or their authorized representative signing a transfer form with an effective date of the transfer noted. There can be NO gap in days between the two hospices or it will be considered a discharge and readmission. The receiving hospice’s claim “from date” must be the same as the transferring hospice’s “through date.”
Service Intensity Add On (SIA)
A service intensity add-on (SIA) payment is made for the social worker visits and nursing visits provided by a registered nurse (RN), when provided during routine home care in the last seven days of life. The SIA payment is in addition to the routine home care rate. The SIA payment is provided for visits of a minimum of 15 minutes and a maximum of 4 hours per day, i.e. from 1 unit to a maximum of 16 units combined for both nursing visit time and/or social worker visit time per day. The time of a social worker’s phone calls is not eligible for an SIA payment.
Coding for COVID-19 Vaccine Shots
COVID-19 | CMS
NHPCO Member Resources and Compliance Guides
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- Hospice Q Codes - Updated June 2021
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Regulations
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- Hospice Care Code of Federal Regulations 42 CFR 418 Subpart G §418.301, §418.302
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Subregulatory Guidance
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- PUB 100-20: Hospice VBID Direct Mailing Notification (January 2023)
- Medicare Claims Processing Manual (cms.gov) Chapter 11 - Processing Hospice Claims
- Medicare Payment Systems - MLN6922507 March 2021 (cms.gov)
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Other Resources
Cross Reference
This section covers Medicare and Medicaid rates and wage index information for the current year as well as future years.
NHPCO Member Resources and Compliance Guides
MEDICARE RATES
Final FY 2025 Rates
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- FY 2025 Final Medicare Hospice Wage Index State County Rate Chart (September 2024)
- Final Hospice Cap for FY 25 is $34,465.34
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Proposed FY 2025 Rates
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- NHPCO FY 2025 Proposed Medicare Hospice Wage Index State County Rate Chart (Updated April 2024)
- Proposed Hospice Cap for FY 25 is $34,364.85
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FINAL FY 2024 Rates
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- NHPCO FY 2024 Final State/County Rate Chart (July 2023)
- Final Hospice Cap for FY 24 is $33,494.01
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Proposed FY 2024 Rates
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- NHPCO Analysis of the FY 2024 Hospice Wage Index and Quality Reporting Proposed Rule (4/4/23)
- NHPCO FY 2024 Proposed State/County Rate Chart (April 2023)
- Proposed Hospice Cap for FY24 is $33,396.55
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FINAL FY 2023 Rates
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- Regulatory Alert: FY23 Final Rule Summary (7/29/2022)
- NHPCO FY23 Final State/County Rate Charts (7/29/22)
- Hospice Cap for FY23 is $32,486.92.
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Proposed FY 2023 Rates
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- NHPCO Talking Points - FY 2023 Hospice Wage Index and Quality Reporting Proposed Rule (05/13/22)
- Regulatory Alert: FY23 Proposed Rule Summary (4/1/22)
- NHPCO FY23 Proposed State/County Rate Charts (4/13/22)
- Hospice Cap for FY23 is $32,142.65
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Final FY 2022 Rates
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- NHPCO FY 2022 FINAL State/County Rate Charts(7/31/21)
- Hospice Cap for FY2022 is $31,297.61
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Proposed FY 2022 Rates
Final FY 2021 Rates
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- NHPCO FY 2021 Final State/County Rate Charts prepared for all counties in all states. Developed by NHPCO with rates based on the July 31, 2020 final rule and the revised wage index values posted by CMS on August 20, 2020.
- Hospice Cap for FY2021 is $30,683.93
- CMS Wage Index Charts (revised August 20, 2020)
- FY2021 Hospice Wage Index final rule
- CMS Fact Sheet on FY2021 Hospice Wage Index final rule
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Final FY 2020 Rates
2019
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- Hospice Caps for FY 2019 is $29,205.44
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MEDICAID RATES
2025
2024
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- FY 2024 Medicaid State/County Rate Charts (updated 2/7/2024)
- CMS Memo on FY 2024 Medicaid Rates
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2023
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- FY 2023 Medicaid State/County Rate Charts (9/29/2022)
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2022
2021
Regulations
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- Hospice Care Code of Federal Regulations 42CFR 418Subpart G §418.306
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Subregulatory Guidance
Education
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- Podcasts
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Physician services under the Medicare Hospice Benefit
When hospice coverage is elected, the beneficiary waives all rights to Medicare Part B payments for services that are related to the treatment and management of his/her terminal illness during any period his/her hospice benefit election is in force, except for professional services of an attending physician, which may include a nurse practitioner or physician assistant.
Terms On Which to Be Clear
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- Medical director / hospice physician
A doctor of medicine or osteopathy, who is an employee or is under contract with the hospice.
- Medical director / hospice physician
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- Attending physician
Under the Medicare hospice benefit, an attending physician is defined as a doctor of medicine or osteopathy or a nurse practitioner or physician assistant who is identified by the patient, at the time he/she elects hospice coverage, as having the most significant role in the determination and delivery of his or her medical care. Payment for physicians, nurse practitioners, or physician assistants serving as the attending physician, who provide direct patient care services (professional services) and who are hospice employees or working under arrangement with the hospice is billed by the hospice to MAC (Part A).
- Attending physician
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- Independent Attending Physician
When hospice coverage is elected, the beneficiary waives all rights to Medicare Part B payments for professional services that are related to the treatment and management of his/her terminal illness during any period his/her hospice benefit election is in force, except for professional services of an independent attending physician, who is not an employee of the designated hospice nor receives compensation from the hospice for those services. The independent attending physician is defined as a doctor of medicine or osteopathy, or nurse practitioner, or physician assistant, who is identified by the individual, at the time he/she elects hospice coverage, as having the most significant role in the determination and delivery of their medical care. Independent attending physicians bill Part B for their services and include Modifier GV to they are not employed or paid by the patient’s hospice provider.
- Independent Attending Physician
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- Nurse Practitioners (NP)
Nurse Practitioners must be the patient’s chosen attending physician in order to bill for services. The only nurse practitioner billing to Medicare (Part A or B) for services related to the terminal illness is if the NP is the attending physician. Nurse practitioners who are not the attending physician cannot bill for services related to the terminal illness. - Physician Assistant (PA)
Physician Assistant must be the patient’s chosen attending physician in order to bill for services. PAs who are not the attending physician cannot bill for services related to the terminal illness.
- Nurse Practitioners (NP)
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- Consulting physician:
Any physician, other than Attending or Medical Director/Hospice Physician, who is providing related services to the hospice. These are non-hospice physicians and when they provide billable services related to the terminal diagnosis they must be billed by hospice to the MAC. The consulting physician charges will be reflected as a separate line item on the hospice claim, if applicable. The Hospice and the consulting physician must have a contract in place for hospice to bill Part A.
- Consulting physician:
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- Related versus unrelated services
Unrelated: Any covered Medicare services not related to the treatment of the terminal condition for which hospice care was elected, and which are furnished during a hospice election period, may be billed by the rendering provider using professional or institutional claims for non-hospice Medicare payment. The rendering provider will bill Medicare and include a Modifier GW, which indicates the service was unrelated to the hospice’s terminal condition.
Related: Any covered Medicare services related to the treatment and management of his/her terminal illness are billed to hospice for Part A billing except for services of the independent attending physician.
- Related versus unrelated services
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- Professional versus technical
Professional Services: Evaluation & Management; Consultative; Interpretative Services are billable to Medicare. For care related to the terminal and related conditions:
- Professional versus technical
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- Hospice employed or contracted physicians’ services are billed by the hospice to Medicare Part A.
- Consulting physicians (under agreement with the hospice) are billed by hospice to Medicare Part A.
- Independent attending physicians bill to Medicare Part B.
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Technical Services: Technical component of diagnostic studies. Services are not billable to Medicare as they are part of hospice per diem.
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- Administrative services
Payment for hospice physicians’ administrative and general supervisory activities is included in the hospice payment rates. These activities include participating in the establishment, review and updating of plans of care, supervising care and services and establishing governing policies.
- Administrative services
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Rural Health Clinics (RHC) and Federally Qualified Health Centers (FQHC)
GV Modifier for RHC and FQHC Attending Physician Claims
CMS has issued CR 12357 and MM 12357 announcing the use of the GV modifier for Rural Health Clinics (RHC) and Federally Qualified Health Centers (FQHC). Beginning January 1, 2022, an RHC or FQHC can bill and get payment under the RHC All Inclusive Rate (AIR) or FQHC Prospective Payment System (PPS), respectively, when their employed and designated attending physician provides services during a patient’s hospice election. To get the RHC AIR or payment under the FQHC PPS:
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- RHCs must report the GV modifier on the claim line for payment (along with the CG modifier) each day they provide a hospice attending physician service
- FQHCs must report the GV modifier on the claim line with the payment code (G0466 – G0470) each day they provide a hospice attending physician service. This applies when a physician, nurse practitioner, or physician assistant working for or under contract to an RHC or FQHC provides hospice attending physician services to a Medicare patient who has elected hospice. This is effective for dates of service on or after January 1, 2022.
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National Provider Identifier (NPI)
The National Provider Identifier (NPI) is a Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard. The NPI is a unique identification number for covered health care providers. Covered health care providers and all health plans and health care clearinghouses must use the NPIs in the administrative and financial transactions adopted under HIPAA. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number). This means that the numbers do not carry other information about healthcare providers, such as the state in which they live or their medical specialty. The NPI must be used in lieu of legacy provider identifiers in the HIPAA standards transactions.
National Provider Identifier Standard (NPI) | CMS
Regulations
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- Hospice Care Code of Federal Regulations 42 CFR 418Subpart G §418.304
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Subregulatory Guidance
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- Medicare Benefit Policy Manual Chapter 9-Coverage of Hospice Services Medicare Benefit Policy Manual (cms.gov)
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Section 40.1.3 - Physicians' Services
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- Medicare Claims Processing Manual (cms.gov) Chapter 11 - Processing Hospice Claims
- Section 40 - Billing and Payment for Hospice Services Provided by a Physician
- Medicare Claims Processing Manual (cms.gov) Medicare Claims Processing Manual Chapter 9 - Rural Health Clinics/ Federally Qualified Health Centers
- Section 60.6 - RHCs and FQHCs for billing Hospice Attending Physician Services
- Medicare Claims Processing Manual (cms.gov) Chapter 12 - Physicians/Nonphysician Practitioners
- Implementation of the GV Modifier for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) for Billing Hospice Attending Physician Services CR 12357
- Implementation of the GV Modifier for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) for Billing Hospice Attending Physician Services MM 12357
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Other Resources
Cross Reference
Medicare-certified institutional providers are required to submit an annual cost report to a Medicare Administrative Contractor (MAC). The cost report contains provider information such as facility characteristics, utilization data, cost and charges by cost center (in total and for Medicare), Medicare settlement data, and financial statement data. CMS updated the cost report forms used by hospices, to be used beginning with FY 2015. The Form CMS-1984-14 is the correct form to use at this time.
Subregulatory Guidance
Hospice Caps
Medicare regulations provide for two caps on Medicare expenditures for hospice care: Inpatient Cap and Aggregate Cap
Self-Determined Hospice Cap (SDHC) Report
Hospices are required to file a self-determined cap no earlier than 3 months after, and no later than 5 months after the end of the hospice cap year, September 30. The earliest a hospice may file its self-determined cap is December 31, and the latest is February 28 of each year.
Self-Determined Hospice Cap (SDHC) Report
Each Medicare Administrative Contractor (MAC) has specific instructions on the completion of the cap report. Ensure that your hospice is completing the cap report and filing it with the appropriate MAC by the February 28/29 deadline.
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- Provider Statistical and Reimbursement (PS&R): Hospices should obtain their Provider Statistical and Reimbursement summary and Hospice Cap reports from the CMS Website. Each MAC has specific instructions on how to gather the necessary data to fill out the cap report, and where to file it. See the links below.
- Aggregate Cap Amount: The IMPACT Act of 2014 changed the cap calculation formula for each year that ends after September 30, 2016 and before October 1, 2025. The Consolidated Appropriations Act, 2021 extended this new cap calculation formula to the year 2030. The Consolidated Appropriations Act, 2022 extended this cap calculation formula until FY 2031. The cap will be annually adjusted using the same hospice payment update percentage that is applied to the rates.
- Change in Cap Year: In the FY2017 Hospice Wage Index Final Rule, CMS announced a change in the cap year, to align it with the federal fiscal year. Medicare FY runs from October 1 to September 30.
- Inpatient Cap
The total payment for inpatient care is subject to a limitation that total inpatient days of care (general or respite) should not exceed 20 percent of the total days for which these patients elected hospice care. At the end of a cap period, the Medicare Administrative Contractor calculates the percentage of inpatient days of care as a part of total days of care. The regulations for payment for inpatient care are found at §418.302(f) Payment procedures for hospice care.
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- Hospice Aggregate Cap
The hospice aggregate cap is an amount set by the Centers for Medicare and Medicaid Services each year that is used to figure, in the aggregate, the maximum amount that a hospice will be reimbursed for Medicare hospice services. The aggregate cap limits the total aggregate payment any individual hospice can receive in a year. A hospice’s ‘‘aggregate cap’’ is calculated by multiplying the number of beneficiaries who have elected hospice care during an accounting year by a per beneficiary “cap amount.” The Act established the per-beneficiary cap amount and provides an annual increase to the cap amount based on the rate of increase in the medical care expenditures category of the Consumer Price Index. A hospice’s aggregate cap is compared with the total Medicare payments made to the hospice during the same accounting year. Any Medicare payments in excess of the aggregate cap are considered overpayments and must be returned to Medicare by the hospice. The regulations for the hospice aggregate cap are found at § 418.309 Hospice cap amount.
- Hospice Aggregate Cap
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NHPCO Member Resources and Compliance Guides
Regulations
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- Medicare Hospice Cap Statute (Social Security Act §1814(i)(2)(A))
- Hospice Care Code of Federal Regulations 42CFR 418
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Subpart G §418.308, §418.309
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- 308 Limitation of amount of hospice payments eCFR :: 42 CFR 418.308 -- Limitation on the amount of hospice payments.
- 309 Hospice aggregate cap eCFR :: 42 CFR 418.309 -- Hospice aggregate cap.
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Subregulatory Guidance
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- Hospices: Aggregate & Inpatient Caps under the Value-Based Insurance Design Model
- Medicare Benefit Policy Manual Chapter 9-Coverage of Hospice Services Medicare Benefit Policy Manual (cms.gov)
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Section 90 Caps and Limitations on Hospice Payments
Other Resources
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- Job Aide Hospice Cap Hospice Financial Caps (Home Health & Hospice)
- Hospice Caps Job Aid (palmettogba.com)
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Medicare beneficiaries that are dually eligible veterans, and reside at home in their community may elect the Medicare Hospice Benefit and have hospice services paid for under the Medicare Hospice Benefit. If a duly eligible veteran, who had been receiving Medicare hospice services in his/her home, is admitted to a VA owned and operated inpatient facility, the beneficiary must revoke the Medicare hospice benefit. Medicare is not allowed to pay for those services for which another federal entity is primary payer. Dually eligible veterans may elect to receive Medicare hospice services while residing in community nursing homes and state homes and have those services paid for under the Medicare Hospice Benefit.
The VA’s Hospice and Palliative Care Program Office’s ongoing position is that “enrolled Veterans have full access to their VA healthcare benefits even if they elect Medicare Hospice, however, VA facilities should collaborate with hospice agencies to avoid duplication of services and ensure that VA provided services are consistent with the hospice care plan.”
Contracting and billing for veterans in community-based hospice care could vary from region to region and can be complex. See the We Honor Veterans website for more information.
Subregulatory Guidance
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- Medicare Benefit Policy Manual Chapter 9-Coverage of Hospice Services Medicare Benefit Policy Manual (cms.gov)
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- 60 - Provision of Hospice Services to Medicare/Veteran’s Eligible Beneficiaries
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- Medicare Benefit Policy Manual Chapter 9-Coverage of Hospice Services Medicare Benefit Policy Manual (cms.gov)
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Care Plan Oversight
Care plan oversight (CPO) is physician supervision of patients under care of hospices that require complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans. Implicit in the concept of CPO is the expectation that the physician has coordinated an aspect of the patient’s care with the hospice during the month for which CPO services were billed. Nurse practitioners, physician assistants, and clinical nurse specialists, practicing within the scope of State law, may bill for care plan oversight. These non-physician practitioners must have been providing ongoing care for the beneficiary through evaluation and management services.
For a physician or non-physician practitioners employed by or under arrangement with a hospice agency, CPO functions are incorporated and are part of the hospice per diem payment and as such may not be separately billed.
HCPCS Code for Hospice Care Plan Oversight: G0182 Can be used by:
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- The attending physician or nurse practitioner (who has been designated as the attending physician) may bill for hospice CPO when they are acting as an “attending physician.”
- An “attending physician” is one who has been identified by the individual, at the time he/she elects hospice coverage, as having the most significant role in the determination and delivery of their medical care. The care plan oversight services are billed using Form CMS-1500 or electronic equivalent.
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CANNOT be used by:
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- A physician or non-physician practitioner employed by or under arrangement with the hospice. The services are incorporated into the hospice per diem payment and may not be separately billed.
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NHPCO Member Resources and Compliance Guides
(Nothing at this time)
Subregulatory Guidance
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- Medicare Claims Processing Manual (cms.gov) Chapter 11 - Processing Hospice
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- 40.1.3.1 - Care Plan Oversight
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- Medicare Claims Processing Manual (cms.gov) Chapter 12 - Physicians/Nonphysician Practitioners
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- 180 - Care Plan Oversight Services
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- Medicare Claims Processing Manual (cms.gov) Chapter 11 - Processing Hospice
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Other Resources
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- American Academy Hospice and Palliative Care American Academy of Hospice and Palliative Medicine (aahpm.org)
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Advance Care Planning: FAQs: CMS posted Frequently Asked Questions (FAQs) on billing Advance Care Planning (ACP) services beginning January 1, 2016. The FAQs are based on policies outlined in the CY 2016 Physician Fee Schedule final rule. For information on billing ACP services as an optional element of an Annual Wellness Visit, see the draft MLN Matters® article – MLN 9271.
Draft Advance Care Planning LCD: CMS is proposing a Local Coverage Determination (LCD) for advance care planning. The CMS Medicare Coverage Database shows a draft LCD (DL 38970). Draft LCDs are not yet final but are available for public viewing.
Advance Care Planning as a Telehealth Service: During the COVID-19 public health emergency, many providers conducted advance care planning using telehealth. In the FY 2022 Physician Fee Schedule final rule, CMS confirmed that advance care planning can be offered through telehealth as an audio-only service.
State Advance Directive Forms: NHPCO has advance directive forms available for every state, available in Caringinfo.org, the NHPCO website for consumers.
Subregulatory Guidance
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- Advance Care Planning (cms.gov)
- Medicare Benefit Policy Manual (cms.gov) Medicare Benefit Policy Manual Chapter 15 – Covered Medical and Other Health Services
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- 280.5.1 – Advance Care Planning (ACP) Furnished as an Optional Element with an Annual Wellness Visit (AWV) Upon Agreement with the Patient
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Hospice pre-election evaluation and counseling services
Medicare allows payment to a hospice for specified hospice pre-election evaluation and counseling services when furnished by a physician who is either the medical director or employee of the hospice. Medicare covers a one-time only payment on behalf of a beneficiary who is terminally ill, defined as having a prognosis of 6 months or less if the disease follows its normal course, has no previous hospice elections and has not previously received hospice pre-election evaluation and counseling services.
Subregulatory Guidance
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- Medicare Claims Processing Manual (cms.gov) Chapter 11 - Processing Hospice Claims
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- Section 10.1 Hospice Pre-election evaluation and counseling services
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- Medicare Claims Processing Manual (cms.gov) Chapter 11 - Processing Hospice Claims
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