Ask-the-Contractor (ACT) Questions and Answers
September 24, 2014, "Change Request 8877: Diagnosis Reporting, and Timely Filing of NOEs and NOTRs"
To access the handouts from this event, click here
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- What will happen if the 8XB is for a benefit period that has not yet been posted to Common Working File?
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CMS and CGS are aware of potential issues with the processing of an 8XB when the discharge/revocation occurs after the last posted benefit period. On November 26, 2014, CMS issued the following message via the MLN Connects Provider eNews
article "Hospice Notices Returned to Provider. The FY 2015 Hospice Final Rule and hospice manual update provided new instructions regarding filing hospice Notices of Termination / Revocation (NOTRs), effective October 1, 2014. If a hospice beneficiary is discharged alive or if a hospice beneficiary revokes the election of hospice care, the hospice will file a timely NOTR, using type of bill 8xB, unless it has already filed a final claim. A timely-filed NOTR is a NOTR that is submitted to and accepted by the Medicare Administrative Contractor within 5 calendar days after the effective date of discharge or revocation.Currently, Medicare systems require that the discharge or revocation date on a NOTR falls within a posted hospice benefit period. Benefit periods are only posted in response to a Notice of Election or to subsequent claims, not in response to the NOTR. In some cases, the discharge or revocation date would fall in a new benefit period but no claims have caused the new benefit period to be posted. In these cases, Medicare systems return the NOTR to the provider with Common Working File (CWF) error codes U5109 or U5114. Medicare is assessing how to correct this system limitation.
In the interim, Medicare considers hospices to have met the filing requirement of a timely-filed NOTR if the NOTRs that they submit are returned for the reason described above. Hospices should file the claim that establishes the current benefit period as soon as possible. The final claim reporting the discharge or revocation can be submitted as soon as the benefit period is posted to CWF. If the final claim is delayed, the NOTR should be resubmitted.
For more information, see MLN Matters® Article MM8877
, "Hospice Manual Update for Diagnosis Reporting and Filing Hospice Notice of Election (NOE) and Termination or Revocation of Election."Reviewed: 09.26.16
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- If the final claim is submitted within 5 days, do we still need to submit an NOTR?
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No, CR 8877 states the hospice must submit an NOTR "unless it has already filed a final claim." Therefore, if a final claim has been submitted within 5 days, the NOTR is not required.
Reviewed: 09.26.16
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- Currently, when I submit an NOE, I don't submit a diagnosis code or a physician NPI/name. Is this something I need to begin doing October 1, or is this something I should have been doing all along?
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It has always been required, although the system does not enforce it. The Medicare Hospice Claims Processing Manual (Pub. 100-04 Ch. 11) indicates that diagnosis code(s) and physician information are required. So you should have been doing this. If not, you should begin reporting this information now.
Reviewed: 09.26.16
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- You suggested a screenprint of ELGH, which we know is going away. Would you suggest screenprints off of myCGS?
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Yes, any eligibility software that you use should allow a screenprint, and you can use that once ELGH is terminated.
Reviewed: 09.26.16
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- We admitted a patient in February with dementia. When I bill claims for them for services starting October 1, will that kick out in error if I report that dementia code as a principal diagnosis?
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Yes, if the diagnosis code that you are currently using as the principal diagnosis is listed in the Change Request (CR), or in Attachment A of the CR, and you report it as a principal diagnosis for services beginning on/after October, that claim will be returned to you for correction. Therefore, you will need to determine a new appropriate diagnosis code as your principal diagnosis.
Reviewed: 09.26.16
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- Can we still use the dementia diagnosis code as a secondary or tertiary diagnosis code?
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Yes, you can still use dementia as a secondary or later diagnosis code; it is just prohibited as the principal diagnosis code.
Reviewed: 09.26.16
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- If we have a patient who revokes October 4 and then they come back to hospice the following week, is that going to be allowable? The final claim will not be billed in time to get the next NOE in timely. Will I be able to bill the NOE even though I did not bill the claim?
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Your notice of termination/revocation (81B) should be submitted on October 4 or within 5 days of the discharge. Once that is in, you should be able to bill your NOE even though you have not billed your final claim.
Reviewed: 09.26.16
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- Is there an actual time of day for consideration of timely filing?
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The system is going to look at midnight as the start and end of a day. We cannot see the hour and minute that a NOE is submitted, but the date stamp when you submit it will be central time. As soon as you F9 (submit) the NOE, it will be received in FISS; there is no time delay.
Reviewed: 09.26.16
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- What happens when a patient gets retroactive entitlement for Medicare? We would not have any screenprints to support our case as to why the NOE was untimely.
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The beneficiary should have received some type of notification about the date of his/her Medicare entitlement. If you can obtain a copy of the beneficiary's letter regarding the retroactive entitlement, that would be sufficient. Any documentation from the beneficiary or Social Security Administration to support the retroactive entitlement would be accepted.
Reviewed: 09.26.16
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- We have a patient who has had several additional development requests (ADRs). He was discharged in March, but his September claim is still in ADR. I tried to submit his March discharge with an NOTR, but there is no March benefit period, so the NOTR is stuck. In these cases, should we still submit the NOTR even though it's for a benefit period that's not yet posted?
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Yes, this is a known issue. If the revocation falls after a posted benefit period, the NOTRs are being returned to the provider for correction or suspending. On November 26, 2014, CMS issued a message via the MLN Connects Provider eNews
with the article "Hospice Notices Returned to Provider". In these cases, the NOTR must still be submitted timely (within 5 days of discharge) in order to be considered timely.Reviewed: 09.26.16
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- On occasion, we have an NOE go into a manual status for review (S M90F1, S M90M1, etc.). How will that be handled for timely filing?
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In these cases, the NOE is searching for the beneficiary's host site at the Common Working File (CWF). As long as the NOE does not hit any edits at CWF, the NOE is considered submitted and accepted timely. The fact that the NOE does not process (i.e. receive a paid date) within the 5 days is not an issue. However, when the NOE goes out to the CWF, and takes 4-5 days to find the beneficiary's information, and then determines the beneficiary's name/HIC is incorrect, the NOE will RTP. An NOE that RTPs is not considered to be accepted. When the NOE is corrected and F9d, it will receive a new receipt date, and at that point, the NOE will likely be beyond the 5 days, and thus considered untimely.
Reviewed: 09.26.16
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- Is there a recommended process for documenting in the medical record the reason for a change in diagnosis? If the medical director is going to make a change to the principal diagnosis, does that need to be documented?
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No, there is no requirement to document that the medical director is going to make a change to the principal diagnosis, When the CGS medical reviewers look at documentation, they are primarily looking to ensure the documentation supports the terminal status; not necessarily what the primary diagnosis is. The fact that the physician is going to change the diagnosis is not an issue, as long as the documentation continues to support the patient's terminal status.
Reviewed: 09.26.16
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- Some of our nursing homes are licensed as skilled care, but they also have different divisions, like long term care, in their facility. Some of our patients reside in the long term care. Is it still appropriate to report these patients with the Q5003?
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If they have different licenses for different wings or floors, talk with the facility and provide the definitions indicated in CR 8877. Ask the facility for input on where the beneficiary is residing so that you can appropriately code the claim.
Reviewed: 09.26.16
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- Can you clarify how we report Medicare secondary payer (MSP) claims under CR 8877? In the past, we have not submitted an NOE when another payer was primary.
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With MSP, the NOE and NOTR should still be reported, and submitted with Medicare as primary. NOEs and NOTRs are not edited for MSP. You still need to bill the primary insurer as you would normally, and when you bill your claims, you will still need to report the primary insurer information on your Medicare hospice claims. If you know a beneficiary has Medicare as secondary, comply with Medicare rules as if Medicare is primary. In the past, we have had cases where the primary insurer later comes back retroactively and says they were not primary, and there was no notice of election on file. In these cases, providers run into issues with noncompliance with Medicare regulations. Therefore, we recommend that when a beneficiary has Medicare as a secondary payer, you comply with all Medicare rules.
Reviewed: 09.26.16
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- Which statuses in FISS are acceptable so that the receipt date will not change?
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Any billing transaction that goes to a "T" status code will receive a new receipt date when you correct it. Rejections would also fall in that category, although when an NOE rejects, the receipt date does not update – you would need to bill a new NOE, which would likely be outside of that 5-day window as well.
Reviewed: 09.26.16
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- The patient has the right to choose an attending physician, but is not required to. If the patient doesn't designate an attending physician, do we leave the attending physician field blank on the NOE and NOTR?
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The reporting requirements of the physician information on the NOE and the NOTR have not changed based on CR 8877. If a patient does not have an attending physician, only the certifying physician information is reported on the NOE and/or NOTR, and this is reported in the Attending Physician field.
Reviewed: 09.26.16
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- If we file an NOE on October 1, and it goes into RTP on October 3, do we still have 5 days from October 3 to correct the NOE?
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No, you have five days from the original admission date. So if your original admission date is 10/1, and the NOE was returned on 10/3 would only have until 10/6 to correct the NOE. It is 5 days after the admit date; not 5 days from the date it is corrected.
Reviewed: 09.26.16
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- How will dark days play into the 5-day rule?
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Dark days stop the processing of claims in the system. Part of what CMS used in consideration of this rule was Sundays, Federal Holidays and dark days. When a dark day is approaching, we would encourage you to submit the NOE prior to the dark day, if possible. But CMS did consider dark days when they came up with the 5-day rule. If the NOE was not submitted prior to the dark day, and it becomes untimely, you would have the right to request an exceptional circumstance, but the intent of the CR is to get NOEs in as possible. If possible, submit the NOE prior to the dark day.
Follow Up: Per clarification received from CMS following the live ACT event, if an NOE is returned as a result of a CWF edit and the dark days become the reason the NOE is accepted late, then an exceptional circumstance would apply.
Reviewed: 09.26.16
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- What if there are missing verbal orders or missing signature for your NOE?
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Your certification is due by the end of the 3rd of calendar day. If you receive your certification timely, you will still have time to submit your NOE. If your certification is not timely, then your date of admission will need to change.
Reviewed: 09.26.16
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- Does the NOE have to have all the diagnoses, or just a primary diagnosis, as long as the claim has all the diagnoses?
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The NOE should be complete and you should report all appropriate diagnoses; not just the principal diagnosis.
Reviewed: 09.26.16
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- The requirement for NOEs to be submitted within 5 days after admission starts 10/1, correct? I have had a few NOTRs that I should have done, but didn't. Do I need to go back and do those now?
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The requirement for timely NOEs is for admissions on/after October 1, 2014. Providers can currently submit NOTRs. What changed with CR 8877 is the requirement to submit the NOTRs within 5 days following a discharge/revocation effective 10/1. You can enter NOTRs for discharges prior to 10/1, but you are not required to do so.
Reviewed: 09.26.16
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- Does the attending physician need to be reported on the election statement?
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The requirement for reporting the attending physician on the election statement was issued by CMS via Change Request 9114
. Beginning with hospice elections on/after May 4, 2015, the hospice's election statement must include information to identify the patient's choice of attending physician. This should include, but is not limited to, the physician's full name, office address, NPI number, or any other detailed information to clearly identify the attending physician.Reviewed: 09.26.16
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- With the 290.0 and ICD-10 codes, does that kick in October 1?
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The first column in the attachment to CR 8877 provides a list of the invalid principal ICD-9 diagnosis codes. When we transition to ICD-10, which is anticipated to occur October 1, 2015, then those ICD-10 codes will be invalid. So 290.0 will not be valid as a principal diagnosis code effective October 1, 2014, and then starting October 1, 2015, when ICD-10 goes in, F03.90 will not be valid as a principal diagnosis.
Reviewed: 09.26.16
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- In the CR 8877 FAQs attached to the handouts, Question #7 asks about the NOE being submitted untimely. What is the distinction when you do make changes versus when you don't make changes to the NOE? Is it if the information is changed, you don't need to resubmit the NOE, but if the information is incorrect, you do need to cancel and resubmit the NOE?
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Yes. If the information has changed (for example, a patient started out with CHF and now has kidney failure), you won't need to correct the NOE or claims. However, for a situation in which CHF was entered as the initial diagnosis, but it should have been kidney failure, or if there were other keying errors, those would need to be canceled and resubmitted. If the wrong physician information is keyed, you would need to cancel the NOE and rebill it. In these cases, because that is within the hospice's control, that would likely not be an exceptional circumstance, and the hospice could be financially responsible for those days.
Reviewed: 09.26.16
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- We have an MSP patient for which we entered an NOE on 10/1. They are in their 3rd benefit period and we haven't been able to bill any claims, and then they are discharged. A pharmacy calls us asking to discharge the patient but because there are no claims billed, when we submit the 81B it does not process. How do we get the pharmacy to know we entered that information in for discharge? Can we do an 81D to remove the hospice benefit period? Can the beneficiary call Medicare about the revocation not being posted?
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You will need to work with the pharmacy or Part D plan. Currently, if the discharge or revocation date is beyond the posted benefit period, the NOTRs will not process. CMS is aware of this. We recommend that you do the best you can to show that the beneficiary has been discharged so that they can get their medications. We would caution against submitting an 81D as you don't want to imply that the beneficiary never received hospice, which can happen if that benefit period is removed. As a reminder, starting 10/1, if you cancel a benefit period, and need to rebill it, then your NOE will likely be untimely and you will be held liable. Yes, the beneficiary can call 1-800-MEDICARE to request assistance in these cases.
Reviewed: 09.26.16
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- We admitted and then discharged a patient. We have not final billed him yet, and we have now readmitted him. We would be okay for this patient since this CR is not effective until 10/1, right?
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Correct, the requirement to submit NOEs and NOTRs within 5 days is effective for admissions/discharges on/after 10/1.
Reviewed: 09.26.16
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- I have a question about correcting an 81B. What if we have filed an election and billed claims for 3 months of service, and they are all settled, and then we file the NOTR with the wrong discharge date? You indicated one option is to submit an 81D; does that mean we have to undo all of our claims before we file the 81D and then we would have to refile the 81A? What about claims prior to the 81D? Do those need to be canceled?
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It depends on your dates of service. The 81D can be submitted to remove the benefit period in which the incorrect discharge date was posted. You will also need to cancel any claims that fall within that benefit period prior to submitting the 81D. Some other Medicare Administrative Contractors (MACs) have reported that by submitting a final claim with the correct discharge date, the incorrect discharge date posted by the 81B may be updated. However, this does not appear to work if the revocation indicator needs to be removed, rather than just updated.
Reviewed: 09.26.16
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- You do not need to file an NOTR if you do your final billing within 5 days, is that correct?
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Yes, that is correct; within 5 days after the discharge/revocation.
Reviewed: 09.26.16
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- If a hospice files the NOTR, but they haven't done their discharge claim, and we do our 81A, will that allow the prior hospice's final claim to pay? Will the NOE be returned because the prior hospice has not billed their final claim?
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Once the NOTR has processed, that will post the revocation to the prior hospice benefit period. That will allow your NOE for the new subsequent benefit period to process.
Reviewed: 09.26.16
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- FISS is not available on Sunday or Federal Holidays, and we know CMS originally wanted NOEs to be submitted with 3 calendar days. Are you aware of any changes in the future that will change FISS availability for later on Saturdays or Sundays?
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We are not aware of any proposal or discussion to expand the hours of FISS availability.
Reviewed: 09.26.16
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- When the benefit period was terminated by the prior hospice, but they have not billed their final claim, will they run into a problem with submitting a final claim for a hospice benefit period when another hospice has billed their NOE?
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If a subsequent hospice has billed a new NOE for the beneficiary, and the prior hospice did not complete their billing, the new NOE will prevent the prior hospice's claims from processing. In this case, the hospices must work together to facilitate the correct processing of the claims/NOE. The need to back out an NOE to allow a prior hospice to complete their billing would support an exception request for an untimely NOE.
Reviewed: 09.26.16
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- Does the Medical director on the NOE need to be the medical director that completes the certification? Or because they are all in the same group, can it be any one of them?
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That question falls outside the scope of Change Request 8877. Please contact the CGS Provider Contact Center for assistance with that question.
Reviewed: 09.26.16
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- The Conditions of Participation for electronic medical record do not free up our certifications for signature until our comprehensive assess is complete, and the COPs provide for 5 days for that to be completed. You can do verbal certification, but did CMS take into account that the COPs allow for 5 days, since we need to have that in place for our NOE?
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We cannot speak on behalf of CMS on the intent of the 5 day rule. There were many comments received on the initial 3-day and subsequent 5-day rule but we don't know if that is something that CMS specifically took into consideration.
Reviewed: 09.26.16
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