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Auxilary Aids & Services

For information about the availability of auxiliary aids and services, please visit: http://www.medicare.gov/about-us/nondiscrimination/nondiscrimination-notice.html

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Jurisdiction 11 Home Health and Hospice
Billing Occurrence Code (OC) 27 and Occurrence Span Code (OSC) 77 and Late Recertifications

Background
Physician Certifications or Recertifications of terminal illness are the CORE of the Medicare Hospice Benefit. The certification of terminal illness for a hospice patient is required at the start of hospice care and for each subsequent benefit period.

  • The certification/recertification may be verbal or written
  • The certification/recertification must be obtained, no later than two calendar days after hospice care is initiated (by the end of the third calendar day) on the initial benefit period and/or the start date of the next benefit period for recertifications
  • If the certification/recertification was received verbally, written certification must be obtained and placed in the patient’s file prior to submitting the claim

Hospice Benefit Periods/Reminders
The hospice benefit periods consist of two 90-day periods, and an unlimited number of 60-day periods. Medicare cannot make appropriate payment without the correct dates of the benefit periods on hospice Notices of Election (NOEs) and claims.

Hospice providers are encouraged to verify whether or not the beneficiary has ever enrolled in hospice or the first day of the next hospice benefit period/date by checking the beneficiary’s entitlement records either through the Interactive Voice Response (IVR) or using Palmetto GBA’s Online Provider Services (OPS). The Health Insurance Query Access (HIQA) in the Direct Data Entry (DDE) system is also available for verifying entitlement records.

Reminders: Occurrence Code (OC) 27
Hospice agencies shall use OC 27 and the date on all NOEs and initial claims following an election of the hospice benefit for all certifications or recertifications.

  • The OC 27 and date cannot occur within the OSC 77 (non- covered days, provider liability) dates
  • OC 27 does not alter or realign the start of the next benefit period in the Common Working File (CWF) when entered on the claim with OSC 77 (see below for instructions)
  • OC 27 and the date identify the beginning of an election period when entered on a claim that does not contain OSC 77

OC 27 and NOEs:

  • Ensure OC 27 is submitted on all NOEs in Field Locator (FL 31–34) of the CMS 1450 (UB-04) claim form
  • The OC 27 date must match the ‘FROM’ date (FL 6) and ‘Admit’ date (FL 12) on the NOE

Example:

The beneficiary elected the hospice benefit on January 15, 20XX. When submitting the NOE, the ‘FROM’ date, 'Admit' date and OC 27 date must reflect the same date of 1/15/XX.

OC 27 and Claims:

  • Ensure OC 27 is submitted on an initial claim (the first claim submitted after the beneficiary has elected the hospice benefit)
  • The OC 27 date must match the ‘From’ date and the ‘Admit’ date on the initial claim

Example: Timely Certification 1st 90-day benefit period begins January 15, 20XX
The beneficiary elected the hospice benefit on January 15, 20XX, and the certification was received on time. When submitting the initial claim, the ‘FROM’ date, and ‘TO’ dates must reflect January 15, to January 31, 20XX. The OC 27 and the date January 15, 20XX is required on the claim. Subsequent claims within this benefit period do not require OC 27.

Example: Timely Certification 2nd 90-day benefit period begins on April 15, 20XX
Following the same dates used in the above example, the first day of the 2nd 90-day benefit period begins April 15, 20XX (90 days from January 15, 20XX). In this example, the certification was received on time. Therefore, the claim is submitted with dates of service April 1 to April 30, 20XX, and must include the OC 27 and April 15, 20XX date. The admit date on this claim does not change. Subsequent claims within this benefit period do not require OC 27.

Reminders: Occurrence Span Code (OSC) 77
When the recertification of the beneficiary’s terminal illness is not received on time, providers are required to enter OSC 77 on the claim and the dates for which the certification was not received on time. OSC 77 and the dates indicate the period of non-covered hospice care. The provider is liable for all days within OSC 77.

*Note: If the recertification is not obtained due to a missed face-to-face encounter, the provider is required to discharge the patient from the hospice Medicare benefit. A claim is not submitted for the dates that the patient was not eligible for hospice. The provider may readmit the patient if he/she chooses to reenroll in the hospice Medicare benefit after the face-to-face encounter has occurred. This will begin a new benefit period.

Example: Untimely Recertification
The new benefit period began on April 15, 20XX; however, the recertification was not received until April 20, 20XX. OSC 77 is used to indicate the non-covered days.

Enter OC 27 (FL 31–34) and the date the certification was actually received; April 20, 20XX.

Enter OSC 77 (FL 35–36) and the 'From' and 'To' dates for the days in which the recertification was not received; April 15, 20XX to April 19, 20XX.

Example: Untimely Recertification overlapping into next benefit period
Following the same dates used in the above examples, the beneficiary elected the hospice benefit on January 15, 20XX. The initial claim was submitted with OC 27 and the date January 15, 20XX, which indicated the certification was received timely (by the end of the third calendar day).

It’s now time to bill the second benefit period (2nd 90 day benefit period), and according to the CWF, the next benefit period starts April 15, 20XX; however the recertification for this benefit period was not received until the May 15, 20XX.

The billing period for the claim is April 1, 20XX, through April 30, 20XX. Since the next benefit period is scheduled to begin April 15, 20XX, the claim for this billing period should reflect OSC 77 with the April 15, 20XX (date the benefit period is scheduled to start based on the CWF) to April 30, 20XX dates. OC 27 would not be entered on this claim.

The claim for the next billing period begins on May 1, 20XX, and ends on May 30, 20XX. Because the certification was not received until May 15, 20XX, enter OSC 77 with the 'From' and 'Through' dates of May 1, 20XX, through May 14, 20XX, due to untimely receipt of the recertification.

The claim shall also include OC 27 and date May 15, 20XX, ('actual date' the recertification was obtained).

Important Note
Providers are reminded that when the OC 27 and date are identified on a claim to capture the 'actual date' a recertification was obtained due to an untimely recertification (OSC 77). In this case, OC 27 does not alter or realign the start of the next benefit period in the CWF. You must verify the next benefit period/OC 27 date PRIOR to billing the benefit period.

When billing for services rendered during non-covered days, the hospice shall include the following information on their claim, in addition to all other required claim information:

DDE Field

Description/Valid Values  

OC

Enter Occurrence Code (OC) 27 and the date that the recertification was received.

OSC

Enter Occurrence Span Code (OSC) 77 to identify the non-covered days. Enter the from and through dates of provider liability.

REV CD

Enter the appropriate level of care and any appropriate discipline revenue code(s) for the dates not covered. Enter a separate line item with the appropriate revenue code(s) for the covered days.

HCPC

Enter appropriate HCPCS “Q” code for each level of care and all other HCPCS as required for disciplines (“G” code), injectable, and infusion pump medications and the infusion pump (if applicable)

TOT UNT

Enter the total units for each revenue code reported on the claim. All level of care revenue codes except 0652, the number of units should be the number of consecutive days at that level of care.

Units for discipline revenue codes and 0652 should be entered as 15-minute increments (ex: 30 minutes = 2 units).

TOT Charge

Enter the total charge for each line item

NCOV CHARGE

Enter non-covered charges for each level of care, all disciplines, medications, and infusion pumps (if applicable) that were provided during the non-covered days


 

last updated on 11/03/2014
ver 1.0.51