Hospice Notice of Election (NOE) and Notice of
Termination/Revocation (NOTR) and Clarification of Site of Service
Codes Q5003 and Q5004
August 29, 2014 05:01 PM
On Friday, August 22, 2014, the Centers for Medicare & Medicaid Services (CMS) released Change Request
8877/Transmittal 3032: Hospice Manual Update for Diagnosis Reporting and Filing Hospice Notice of Election
(NOE) and Termination or Revocation of Election. CR8877 provides instruction to hospices and MACs on
processing NOEs and NOTRs, exceptions to timely filing requirements for these notices, and provides
clarification on site of service codes Q5003 and Q5004.
As finalized by CMS in the FY2015 Final Rule, timely-filed hospice NOEs shall be filed by the hospice and
accepted by the Medicare administrative contractor (MAC) within 5 calendar days after the hospice admission
date. A timely-filed NOTR shall be filed by the hospice and accepted by the MAC within 5 calendar days after
the hospice discharge/revocation date unless a final hospice claim has been filed. An NOTR does not need to
be completed in cases where the patient is discharged due to death.
In cases when the NOE is not timely filed, a hospice is responsible to provide care and not charge the
beneficiary for any days of hospice care from the hospice admission date to the date the NOE is submitted to,
and accepted by, the Medicare contractor. Hospices will report these non-covered days on the claim with an
occurrence span code 77, and charges related to the level of care for these days will be reported as noncovered, or the claim will be returned to the provider (RTP). There is currently no consequence to a hospice
for not timely filing the NOTR.
There are four possible exceptions to the timely filing of an NOE. The hospice must request the exception. If it
is approved the provider liable days are waived. The four circumstances that may qualify the hospice for an
exception to the consequences of filing the NOE more than 5 calendar days after the hospice admission date
are as follows:
1. fires, floods, earthquakes, or other unusual events that inflict extensive damage to the hospice’s ability to
operate;
2. an event that produces a data filing problem due to a CMS or Medicare contractor systems issue that is
beyond the control of the hospice;
3. a newly Medicare-certified hospice that is notified of that certification after the Medicare certification date, or
which is awaiting its user ID from its Medicare contractor; or,
4. other circumstances determined by the Medicare contractor or CMS to be beyond the control of the hospice.
Regardless of the reason a hospice is requesting an exception, the hospice shall file the associated claim with
occurrence span code 77 used to identify the non-covered, provider liable days. The hospice shall also report a
KX modifier with the Q HCPCS code reported on the earliest dated level of care line on the claim. The KX
modifier shall prompt the Medicare contractor to request the documentation supporting the request for an
exception. Based on that documentation, the Medicare contractor shall determine if a circumstance
encountered by a hospice qualifies for an exception.
If the request for an exception is approved by the Medicare contractor, the Medicare contractor will process the
claim with the CWF override code and remove the submitted provider liable days, which will allow payment for
the days associated with the late-filed NOE. If the Medicare contractor finds that the documentation does not
support allowing an exceptional circumstance, the Medicare contractor will process the claim as submitted. It is
important to note that CMS has identified that due to a systems limitation, remittance advice remark code N211
(you may not appeal this decision) will be applied to the provider liable days in error. These days are
appealable and CMS plans to release a correcting change request in the future.
CMS provided instructions to MACs to approve requests for exceptions in cases where sequential billing
requirements necessitate a second hospice provider removing its timely-filed NOE and any claims so that a
previous provider can bill. Upon resubmitting the NOE, the second provider’s NOE would appear to the system
to be filed late when in fact it wasn’t. In these scenarios, the hospices that had to back out its NOE should file
the claim with KX modifier and the occurrence span code 77 as required. The MAC should then approve the
request once it has received the required documentation and process the claim without the provider liability
days.
CMS reiterated that hospice personnel issues; internal IT systems issues that the hospice may experience; the
hospice not knowing the requirements; and failure of the hospice to have back-up staff to file the NOE do not
qualify as exceptional circumstances.
In addition to the NOE and NOTR instructions, CMS provided clarification of how to use site of service codes
Q5003 and Q5004. Q5004 shall be used for hospice patients in a skilled nursing facility (SNF), or hospice
patients in the SNF portion of a dually-certified nursing facility. There are 4 situations where CMS indicates this
would occur:
1. If the beneficiary is receiving hospice care in a facility that is only certified as a SNF (it is not dually certified).
2. If the beneficiary is receiving general inpatient care in the SNF.
3. If the beneficiary is in a SNF receiving SNF care under the Medicare SNF benefit for a condition unrelated to
the terminal illness and related conditions, and is receiving hospice routine home care; this is
uncommon.
4. If the beneficiary is receiving inpatient respite care in a SNF.
If a beneficiary is in a nursing facility but doesn’t meet the criteria above for Q5004, the site shall be coded as
Q5003, for a long-term care nursing facility.
CMS manuals will be updated to reflect these instructions. The clarification of the site of service codes, per
CMS, is not a change in policy and hospices should begin following these clarified definitions now. The NOE
and NOTR requirements go into effect on October 1, 2014. Hospices should be submitting the NOE as soon
as possible after admission now but there will be no consequences for late filing until October.
Some hospices have reported attempts to file a NOTR now that has resulted in a rejection. The Hospice
Association of America (HAA) understands this issue is being addressed and it is expected that hospices will
be able to file the NOTR without rejection by October 1, 2014.
Recommendations:
1. Begin filing the NOE as soon as possible after admission but no later than 5 days after admission now in
order to avoid unforeseen issues in accomplishing this after October 1
2. Ensure adequate plans and processes (i.e. back up staffing) are in place to ensure timely filing of the NOE
and NOTR
Reminder: the NOE can only be submitted via DDE, mail or messenger. Therefore, each
hospice should have a back-up plan for submission if its DDE submission capabilities are interrupted.
3. Ensure appropriate use of the Q5003 and Q5004 site of service HCPCS codes now. This may require
modification to existing policies and processes for patients residing in dually-certified facilities. For
instance, the hospice will need to know which portion of the building the patient resides in.
NAHC does have some outstanding questions for CMS and the MACs regarding CR8877 and will be sharing
answers with members as we receive them.