Hospice:
Kick Hospice Consult Kickbacks To The Curb
Published on Mon Mar 07, 2005
CMS issues instructions on hospice pre-election evaluation and counseling services. If your hospice medical director isn't furnishing evaluation and counseling services under new billing code G0337, you're missing out on a potential source of revenue. But you'll have to mind your P's and Q's when using the new benefit.
Congress mandated the service in the Medicare Modernization Act of 2003 and it took effect Jan. 1 this year (see Eli's HCW, Vol. XIII, No. 40, p. 316). "It's a good thing," praises attorney Connie Raffa with Arent Fox in New York City. "People don't know about end-of-life care," and this service allows them to find out about it from an expert without committing to the hospice benefit, which requires them to forego curative treatment for their terminal illness.
In the wake of the Terri Schiavo case, Medicare beneficiaries are seeking end-of-life care information more than ever, Raffa notes.
But that doesn't mean the new service is easy to bill for. "There are lots of different hoops to jump through to do it right," Raffa acknowledges.
In a Medlearn Matters article on the topic revised March 25, the Centers for Medicare & Medicaid Services notes these issues regarding the service: Six-month prognosis. Like the hospice benefit, the pre-election evaluation and counseling requires a six-month prognosis, CMS notes. But unlike the hospice benefit, a physician doesn't have to certify the prognosis. The referring physician must include a "determination of the terminal diagnosis," but actual "certification of the terminal diagnosis is not required," CMS clarifies.
"The standard to 'determine' the terminal status is less stringent than certification," notes Burtons-ville, MD-based health care attorney Elizabeth Hogue. "This language is consistent with the whole purpose of the benefit, which is to evaluate patients' appropriateness for hospice care."
But even this relaxed standard is too strict a requirement, argues John Mahoney, principal of the Summit Business Group in Penfield, NJ. "That a person be terminally ill with a prognosis of six months or less to obtain this consult benefit is an absurd restriction," criticizes Mahoney, former president of the National Hospice Organization.
"In just about any other context any physician can ask another physician for a consult," Mahoney tells Eli. "But under this rule, in order for a physician or beneficiary to ask a most knowledgeable resource (i.e., a hospice physician) for a consult ... the patient not only has to be very sick, they have to be dying, and dying very soon." Kickbacks. "Payments by hospice agencies to physicians or others in a position to refer patients for services furnished under this provision may implicate the Federal anti-kickback statute," CMS warns in the article. A medical director or other physician must be employed by the hospice to furnish this [...]
