CMS To Implement Claim Edit for Hospice Transfers

In July 2022 a claims processing edit to prevent gap billing between hospice transfers will be implemented. An individual may change, once in each benefit period (90-day or 60-day), the designation of the particular hospice from which he or she elects to receive hospice care.

The change of the designated hospice is not considered a revocation of the election but is a transfer. Hospice transfers must occur on the same day. There cannot be a break in hospice care or a gap in billing.

A gap is most likely to occur in situations where a patient requests to transfer to a hospice that is outside of the geographic service area and requires some time of travel.  If the transferring hospice cannot arrange care until the beneficiary reaches the new hospice, the hospice may discharge the beneficiary. This way, if the patient requires medical treatment while in the process of transferring, he/she can access it under his/her traditional Medicare coverage. This would terminate the beneficiary’s current benefit period and require the beneficiary to re-elect hospice coverage at the new hospice and begin a new benefit period.

Per Transmittal 11258/Change Request (CR) 12619 Gap Billing Between Hospice Transfers, which provides instructions to the Medicare Administrative Contractors (MACs) to implement the edit and updates Chapter 11 of the Medicare Claims Processing Manual to reflect that there must not be a gap in billing for hospice transfer situations, a hospice transfer will be rejected if the transfer does not occur immediately. If the receiving hospice’s claim “from date” is not the same as the “through date” with “patient status” indicating a transfer (codes 50 or 51), the transfer will be rejected and the claim returned to provider (RTP).

Given that hospices bill for the date of discharge or transfer, for claims purposes, the “From” date for the receiving hospice must be the same as the “through” date for the transferring hospice, otherwise this would constitute a gap in care and a gap in billing and would not be considered a transfer. For example, if a beneficiary designates that a transfer is to be effective on January 10th, the transferring hospice’s “through” date must be January 10th and the receiving hospice’s “From” date must be January 10th in order to be a continuous hospice election without a gap in care or billing. That is, the transferring hospice is responsible for the beneficiary up until and including the transfer date.

Transfers are not allowed from the same provider. Hospices must not submit an 8XC if the CMS Certification Number (CCN) is the same.