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 page 2 of the Health Insurance Query Access (HIQA) in the Direct Data Entry (DDE) system.
Reminders: Occurrence Code (OC) 27
Hospice agencies should use Occurrence Code (OC) 27 and the date on all NOEs and initial claims following an election of the hospice benefit when certifications or recertifications are received ‘timely’ (by the end of the third calendar day).
- The OC 27 and date cannot occur within the Occurrence Span Code (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)
- Occurrence Code (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
The beneficiary elected the hospice benefit on January 15, 2010. When submitting the NOE, the ‘FROM’ date, 'Admit' date and OC 27 date must reflect the same date of 1/15/10.
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, 2010
The beneficiary elected the hospice benefit on January 15, 2010. When submitting the initial claim, the ‘FROM’ date, and ‘TO’ dates must reflect January 15, to January 31, 2010. In this example, providers may only indicate OC 27 if the certification was obtained timely (by the end of the third calendar day). The OC 27 and the date January 15, 2010 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, 2010
Following the same dates used in the above example, the first day of the 2nd 90-day benefit period begins April 15, 2010 (90 days from January 15, 2010). In this example, providers may only indicate OC 27 and the date April 15, 2010, if the certification was obtained timely (by the end of the third calendar day). A claim with dates of service April 1 to April 30, 2010, must include the OC 27 and April 15, 202010 date. Subsequent claims within this benefit period do not require OC 27.
Reminders: Occurrence Span Code (OSC) 77
When the certification or recertification of the beneficiary’s terminal illness is not received on time, providers are required to enter OSC 77 (Provider Liability Period) on the claim and the dates for which the certification was not received (not received by the end of the third calendar day). OSC 77 and the dates indicate the period of non-covered hospice care.
Example: Untimely Recertification
The new benefit period began on April 15, 2010; however, the recertification was not obtained until April 20, 2010. OSC 77 is used to indicate the non-covered days.
Enter OC 27 (FL 31–34) and the date the certification was actually obtained; April 20, 2010.
Enter OSC 77 (FL 35–36) and the 'From' and 'To' dates for the days in which the recertification was not received; April 15, 2010 to April 19, 2010.
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, 2010. The initial claim was submitted with OC 27 and the date January 15, 2010, which indicated the certification was received timely (by the end of the third calendar day).
It’s now time to bill the 2nd benefit period (2nd 90 day benefit period), and according to the CWF, the next benefit period starts April 15, 2010; however the recertification for this benefit period was not received until the May 15, 2010.
The billing period for the claim is April 1, 2010, through April 30, 2010. Since the next benefit period is scheduled to begin April 15, 2010, the claim for this billing period should reflect OSC 77 with the April 15, 2010 (date the benefit period is scheduled to start based on the CWF) to April 30, 2010 dates. OC 27 would not be entered on this claim.
The claim for the next billing period begins on May 1, 2010 and ends on May 30, 2010. Because the certification was not received until May 15, 2010, enter OSC 77 with the 'From' and 'Through' dates of May 1, 2010 through May 14, 2010, due to untimely receipt of the recertification.
The claim shall also include OC 27 and date May 15, 2010, ('actual date' the recertification was obtained).
Providers are reminded that there are circumstances when the OC 27 and date are identified on a claim to capture the 'actual date' a certification 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.
Billing Reminders for OSC 77
Services rendered during non-covered days OSC 77
- Enter the appropriate level of care (0651, 0652, 0655, and/or 0656) revenue code for each date not covered
- One revenue code per line, per day for each level of care provided during the non-covered period of time in which the certification/recertification was not received (FL 42)
- Enter appropriate HCPCS “Q” code for each level of care (FL 45)
- Enter appropriate discipline revenue codes (055X, 056X, 057X, 044X, 042X, 043X) for each date not covered
- Enter appropriate HCPCS 'G' code for each discipline (FL45)
- Enter number of units (FL 46)
- For all level of care revenue codes except 0652, the number of units should be 1
- Units for discipline revenue codes should be entered as 15-minute increments (applies to service dates on or after January 1, 2010)
- Enter non-covered charges for each line (FL 48)
- Enter total non-covered charges and units (0001 revenue code line)
All other information for services rendered during the covered days should be entered as usual.