Eli's Hospice Insider

Published on Mon Nov 17, 2014 PDF

You may have to tweak your information-gathering for nursing home residents.

Question: How do we know whether to code Q5003 or Q5004 for our hospice patient who resides in a nursing home?

Answer: “We have clarified the differences between site of service HCPCS codes Q5003 and Q5004, and replaced the previous description of the differences with the following language,” the Centers for Medicare & Medicaid Services notes in Change Request 8877. “Q5004 shall be used for hospice patients in a skilled nursing facility (SNF), or hospice patients in the SNF portion of a dually-certified nursing facility. There are 4 situations where this would occur:

1. If the beneficiary is receiving hospice care in a solely-certified SNF.
2. If the beneficiary is receiving general inpatient [GIP] care in the SNF.
3. If the beneficiary is in a SNF receiving SNF care under the Medicare SNF benefit for a condition unrelated to the terminal illness and related conditions, and is receiving hospice routine home care; this is uncommon.
4. If the beneficiary is receiving inpatient respite care in an SNF.”

Clarification: “If a beneficiary is in a nursing facility but doesn’t meet the criteria above for Q5004, the site shall be coded as Q5003, for a long term care nursing facility,” CMS explains in the CR.

Don’t wait: “Ensure appropriate use of the Q5003 and Q5004 site of service HCPCS codes now,” the National Association for Home Care & Hospice advises its members. “This may require modification to existing policies and processes for patients residing in dually-certified facilities. For instance, the hospice will need to know which portion of the building the patient resides in.”

Note: See the transmittal at www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3032CP.pdf.