Transition of Care for Medicare

[olyababi]

Medicare denied TCM claim with denial code PR-B9-Patient is enrolled in hospice.
Does anybody know what to code in this case?

Thank you!

 

[jhendrix08]

So, you can't see the patient for any Dx related to the reason they are on hospice. For example, if patient is on hospice due to a cancer dx, you can't see them and bill for anything related to that disease. We are an internal medicine practice (PCP) so we have had this happen before. Once on hospice, our provider asks that the hospice physician take over the patient's care. Unfortunately, in your case, unless the patient is NOT on hospice (which you can appeal) the chances of getting your claim paid is very low.

Hope that's helpful.

 

[fwnewbie]

So, is cancer-related pain in a hospice situation coded only as Pain or Chronic Pain since the treatment itself (pain med) does not treat the cancer itself?

 

[SharonCollachi]

Hospice care is comfort care, and is not designed to treat the illness. Also, medicare specifically states it includes all services for pain relief:

Hospice care​

To qualify for hospice care, a hospice doctor and your doctor (if you have one) must certify that you’re terminally ill, meaning you have a life expectancy of 6 months or less. When you agree to hospice care, you’re agreeing to comfort care (palliative care) instead of care to cure your illness. You also must sign a statement choosing hospice care instead of other Medicare-covered treatments for your terminal illness and related conditions. Coverage includes:

• All items and services needed for pain relief and symptom management
• Medical, nursing, and social services
• Drugs for pain management
• Durable medical equipment for pain relief and symptom management
• Aide and homemaker services
• Other covered services you need to manage your pain and other symptoms, as well as spiritual and grief counseling for you and your family.

Medicare-certified hospice care is usually given in your home or other facility where you live, like a nursing home.

Your costs in Original Medicare​

• You pay nothing for Hospice care.
• You may need to pay a Copayment of no more than $5 for each prescription drug and other similar products for pain relief and symptom control while you're at home. In the rare case your drug isn’t covered by the hospice benefit, your hospice provider should contact your Medicare drug plan to see if it's covered under Part D.
• You may need to pay 5% of the Medicare-approved amount for inpatient respite care.
• Medicare doesn't cover room and board when you get hospice care in your home or another facility where you live (like a nursing home).