Hospice Monthly Billing Requirement

Published 09/02/2020

Palmetto GBA is reminding the hospice provider community that they must bill in monthly increments.

The Centers for Medicare & Medicaid Services (CMS) Internet Only Manual (IOM) Publication 100-04, Medicare Claims Processing Manual, Chapter 11 – Processing Hospice Claims, Section 90 states: “Hospices must bill for their Medicare beneficiaries on a monthly basis. Monthly billing should 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”.

The CMS IOMs are located on the CMS website.  

Further, the Code of Federal Regulations (CFR) 42 Part 418 – Hospice Care outlines the Medicare Conditions of Participation. This part of the CFR implements Sections of the Social Security Act (the Act) which specifies services covered as hospice care and the conditions that a hospice program must meet in order to participate in the Medicare program. This section of the Act also specifies coverage and payment policy. Upon approval and subsequent issuance of hospice agency certification, the provider agrees to the regulations set forth in 42 CFR Part 418 – Hospice Care.

Hospice providers should only bill one claim per month, per patient in order to be in compliance with Medicare regulations. Hospice providers may not submit weekly claims and claims may not span from one month to the next.

For admissions, the first claim will be dated from admission through the end of the month even if this initial claim spans only several days. Subsequent claims will be submitted as the entire calendar month until a discharge claim is submitted.

There are instances whereby a hospice may need to submit a claim for a period of time less than a calendar month. The following types of bill (TOB) are the only exception to the monthly calendar billing requirement and may be acceptable:

  • TOB 811/821 - Admit Through Discharge Claim. This code is used for a bill encompassing an entire course of hospice treatment for which the provider expects payment from the payer, i.e., no further bills will be submitted for this patient. This is considered a discharge claim.
  • TOB 812/822 – Interim First Claim. This code is used for the first of an expected series of payment bills for a hospice course of treatment. As mentioned above, this is an admission claim.
  • TOB 814/824 – Interim Last Claim. This code is used for a payment bill that is the last of a series for a hospice course of treatment. The 'Through' date of this bill is the discharge date, transfer date, or date of death.

Additional information may be found at: CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 1 – General Billing Requirements, Section 50.2.3 and 50.2.4.

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