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Untimely Face-To-Face Encounter

Untimely Face-To-Face Encounter

The Medicare Claims Processing Manual (CMS Pub. 100-04), Ch. 11, § 30.3External PDF states that when a required face-to-face (FTF) encounter does not occur timely (within 30 days prior to the start of the 3rd or later benefit period), the beneficiary cannot be recertified, and thus, the patient would cease to be eligible for the Medicare hospice benefit. In these cases, the hospice must discharge the patient because he/she is no longer considered terminally ill for Medicare purposes.

NOTE: When a hospice claim is selected for medical review, and the reviewer determines that the face-to-face encounter was untimely, the Occurrence Code (OC) 48 will be added to the claim, and the dates of service following the date the encounter was required will be noncovered. The Common Working File (CWF) will automatically be updated to show the OC 48 date as the date of revocation on the current benefit period. Therefore, a discharge claim is not required. Once the encounter occurs, the patient can be readmitted, provided they meet all of the eligibility requirements, and a new Notice of Election will need to be submitted.

Discharge Claim

In addition to the usual hospice claim information, the discharge claim should include the following information.

(FISS Page 01)
Enter 8X1 or 8X4
Note: X = 1 (non-hospital based) or 2 (hospital based)
(FISS Page 01)
Enter the "from" date for the billing period.
(FISS Page 01)
Enter the "to" date as the last payable day, which is the last covered day in the benefit period.
(FISS Page 01)
Enter '01' if the patient was discharged to home or self-care. Refer to the National Uniform Billing Committee (NUBC) Official UB-04 Data Specifications Manual at www.nubc.orgExternal Website for a list of all patient status codes.
(FISS Page 01)
Enter remarks indicating the reason for the discharge is due to an untimely face-to-face encounter. Include your initials and the date the remark was entered.

When the only reason the patient ceases to be eligible for the Medicare hospice benefit is the hospice's failure to meet the FTF requirement, the Centers for Medicare & Medicaid Services (CMS) expects the hospice to continue to care for the patient at its own expense until the required encounter occurs. Once the encounter occurs, the patient can be readmitted, provided they meet all of the eligibility requirements, and the patient files a new election statement.

Updated: 04.11.16


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