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CMS Issues CR6778: Claims System Edits

To:        NHPCO Membership
From:   NHPCO Regulatory Team
Re:        February 11, 2010


Summary at a Glance:

CR 6778 describes system edits that will become effective for claims submitted on or after July 6, 2010.  The two edits include: 

  • Common Working File changes which will allow claims to be processed for both Medicare Advantage and Medicare hospice services on the date of the hospice election.
  • Edits on the level of care and sites of service where care at that level of care is allowed.Of special note is a description of where continuous home care can be provided – and only the patient’s home is allowed in this CR.

In addition, CR 6778 provided a technical correction regarding calculation of continuous care hours stating “nursing care must be provided for ‘more than half’ of the period of care.”

On February 5, 2010, CMS issued CR6778, which describes Medicare systems edit refinements related to hospice services for Medicare Advantage and site of service.  While the system refinements are revisions to the Medicare system to allow for payments, new edits ensuring that the site of service is appropriate for the level of care being provided are new and may be a significant change for some providers.  The chart below describes where the level of care cannot be provided.  The edits will be effective for claims submitted on or after July 6, 2010. 

Place of Service for GIP, Respite and Continuous Home Care

CMS is implementing several edits within the claims processing system to ensure that hospice days are billed at the appropriate setting.  The following chart may be helpful.  The following HCPCS site of service codes will NOT be allowed:

Provider claims will be “Returned to Provider” (RTP) if the level of care is provided at the wrong site of service. 

Medicare Advantage and Beneficiaries Electing Hospice Care:

On or after July 6, 2010, the Common Working File (CWF) will allow claims to be processed for both the Medicare Advantage plan and Medicare hospice for services occurring on the date of the hospice election.  This will prevent services provided on the date of the election from rejecting as MA Plan responsibility.  Providers that have claims being disputed may resubmit their claims on or after July 6, 2010 to the appropriate FFS Medicare contractor for payment consideration.  Contractors will not be required to provide automated adjustments. 

Calculating the Hours of Nursing and Aide Services in Continuous Care

CMS has made a technical correction to the manual, Publication 100-04, Section 30.1 with the following change:  “Nursing care must be provided for more than half of the period of care…”

Additional Questions

NHPCO has asked CMS for additional clarification on several questions raised by this CR and will follow up with a Regulatory Alert with any answers to those questions.  If providers have questions, please send them to regulatory@nhpco.org and we will compile the questions in our conversations with CMS.