Demand Billing for Hospice General Inpatient Care

100.2 - Demand Billing for Hospice General Inpatient Care (Rev. 2748, Issued: 07-26-13, Effective: 01-01-14, Implementation: 01-06-14) The Advanced Beneficiary Notice of Non-coverage (ABN), Form CMS-R-131, is issued by the hospice to Medicare beneficiaries in situations where Medicare payment is expected to be denied. ABN issuance is mandatory when the level of hospice care is determined to be not reasonable or medically necessary as defined in §1862(a)(1)(A) or §1862(a)(1)(C). When a Medicare hospice beneficiary has been receiving covered general inpatient care (GIP) and the hospice determines that continued hospice GIP care is not reasonable and medically necessary, the provider must issue an ABN. Billing instructions for demand bills associated with ABN issuance are provided in this manual in Chapter 1 General Billing Requirements, section 60.4.1 Outpatient Billing with an ABN (Occurrence Code 32). Hospices should be aware Medicare may require suspension of any claims using occurrence code 32 for medical review of covered charges associated with an ABN. A/B MACs (HHH) reviewing GIP reported on a hospice claim with an ABN provided may conclude the care is not reasonable and medically necessary. When the A/B MAC (HHH) makes the non-coverage determination, they must non-cover the GIP line item(s) on the claim. Hospices may be paid the routine home care (RHC) rate in lieu of the denied GIP service. The A/B MAC (HHH) adds a line item for RHC (revenue code 0651) for each denied GIP line. The charges associated with the added RHC line should be the RHC charges the hospice reports on their claim or in the absence of a hospice submitted RHC line item, the A/B MAC (HHH) shall enter the applicable RHC base rate. These instructions are not applicable when the beneficiary is not questioning the Medicare coverage but needs a Medicare denial for a secondary payer. In those cases, the provider should submit a non-covered claim with the condition code 21.