Historically, Medicare hospice claims have contained fairly limited information, at least as compared to claims for other provider services. As of January 1, 2008, this will change. Hospices will be required to report an expanded level of claims data in order to receive payment from Medicare. CMS believes that the heretofore limited claims data reported by hospice providers has "restricted Medicare's ability to ensure optimal payment accuracy in the hospice benefit, and to carefully analyze the services provided…." Medicare's new claims submission guidelines ostensibly will solve this problem by providing Fiscal Intermediaries with far more detailed information to use in their analyses of the necessity and propriety of services provided.

Beginning the first of the new year, hospice providers will be required to indicate "the number of services/visits provided by nurses (registered, licensed, and/or nurse practitioner), home health aides, social workers, physicians and nurse practitioners serving as the beneficiary's attending physician" during each Sunday-to-Saturday week. This list must indicate the number of visits performed by each provider type, not an aggregate number. Only "direct patient care visits" are counted; items and services provided during a visit are not separately counted and neither chart entries (without a visit) nor visits made as part of facility rounds are considered "direct patient care visits." Further, each line item must also indicate the appropriate code for each site where each visit is made, and, should the site of service change, a separate line will be required to reflect the site where the direct patient care was provided. These changes, of course, will require changes in the way facilities code for various services and levels of care.

Notably, CMS' guidance also specifically reminds providers that separately billed visits by physicians or nurse practitioners serving as the attending physician may only be counted where they are "medically reasonable and necessary." The guidance also notes that the itemized visit count requirement for nurses, home health aides, and social workers is not for the purposes of separate payment, but "to provide transparency into the services that are being provided to beneficiaries who are electing the Medicare hospice benefit."

Ober|Kaler's Comments: These CMS statements may indicate an increased level of compliance and enforcement attention on the near horizon. Facilities should begin now to implement the record keeping, compliance and coding changes that will be necessary to meet the new year's requirements. Facilities should also take this time to review their existing record keeping and compliance practices to ensure that they are prepared in the event that this change does foreshadow increased levels of CMS enforcement attention.

For more detailed CMS guidance, see MLN Matters Number MM5567 and http://www.cms.hhs.gov/Transmittals/downloads/R1304CP.pdf.