CMS Releases New Condition Code 85 to Use When Hospice Recertification Is Untimely with Corrections to Hospice Processing Problems

Posted on Wednesday, August 10, 2016 2:47 PM

On August 5, the Centers for Medicare & Medicaid Services (CMS) released the Change Request (CR) 9590, New Condition Code To Use When Hospice Recertification Is Untimely and Corrections to Hospice Processing Problems.

This CR creates a new condition code 85, which will be used when the hospice receives the recertification of terminal illness later than 2 days after the first day of a new benefit period. Additionally, this code is reported with occurrence span code (OSC) 77.

The new condition code 85 is effective on January 1, 2017, and is defined as “Delayed recertification of hospice terminal illness.” When hospices report this code, Medicare systems will make sure the occurrence code 27 date does not fall within the OSC 77 dates.

CMS is working on problems associated with the new hospice payment system. The system problems (which will also be corrected effective January 1, 2017) include the following:
• Systems not counting all hospice benefit period days when the period is not separated by 60 days for purposes of determining whether a high or low RHC payment should be paid
• Systems not looking back at a prior month’s claim in some situations to determine if there are SIA-eligible visits that should be paid
• Systems incorrectly recouping SIA payments in error if a provider subsequently adjusts the claim again

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