Medicare Hospice

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Hello,
I work as a Medicare Insurance Follow-Up representative (my first job since earning my CPC-A in August) for the physician billing dept of a large healthcare system. One of the biggest confusions I've had for the last 9 months has to do with Medicare hospice claims. My co-workers and I all have a different idea on how this should work and I really need some clarification, as I can't find the answer: When Medicare denies a claim for "patient enrolled in hospice." we gather the hospice (name, address, phone #) info and verify the admitting Dx code, effective dates in hospice, and the attending physician. When deciding whether the claim needs a GV or GW modifier, we compare the Dx code on the denied claim and the admitting Dx code of the hospice. We are asked, "are the Dx codes related?" My question is, what exactly does "related" mean?? Does related mean, the Dx codes are EXACT? Or does related mean, the codes can be in the same category (for instance, J18.9 vs. J43.1...they are not exact, but are both J codes, so they're considered related).
I have been told to do it both ways, but need the correct answer! I would love to be able to share the proper info with my team. I hope this makes sense! Thank you in advance
 

SharonCollachi

True Blue
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The National Association for Homecare & Hospice has this to say:

9/30/2019: Related vs Unrelated - Who Decides Relatedness?
•Medical Director should have major role along with IDG
•So IDG staff will need to determine specifically which diagnoses are related each month
•Those diagnoses are placed on the claim
•Those diagnoses will be used to manage ALL covered services– Physician visits– ED/hospital visits– Procedures/interventions– Tests/labs– Equipment– Medications

AND

Related conditions: “Clinically, related conditions are any physical or mental condition(s) that are related to or caused by either the terminal illness or the medications used to manage the terminal illness.”

AND they say this is from CMS: Those conditions that result directly from terminal illness; and/or result from the treatment or medication management of terminal illness; and/or which interact or potentially interact with terminal illness; and/or which are contributory to the symptom burden of the terminally ill individual; and/or are conditions which are contributory to the prognosis that the individual has a life expectancy of 6 months or less.

CMS stated: ‘‘. . . we believe that the unique, physical condition of each terminally ill individual makes it necessary for these decisions to be made on a case-by-case basis. It is our general view that hospices are required to provide virtually allthe care that is needed by terminally ill patients.’’ Therefore, unless there is clear evidence that a condition is unrelated to the terminal prognosis; all conditions are considered to be related to the terminal prognosis.•It is also the responsibility of the hospice physician to document why a patient’s medical needs will be unrelated to the terminal prognosis.
 
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