This article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Hospice - Determining Terminal Status.
National Coverage Provisions:
With passage of the Affordable Care Act in March 2010, Congress required hospice physicians or hospice nurse practitioners to have a face-to-face encounter with Medicare hospice patients prior to the 180th-day recertification and every recertification thereafter, and to attest that the encounter occurred. CMS proposed and implemented policies related to this new requirement in the Home Health Prospective Payment System Rate Update for CY 2011; Changes in Certification Requirements for Home Health Agencies and Hospices Final Rule (75 FR 70372). This new face-to-face encounter requirement became effective on January 1, 2011.
Hospice certifications and recertifications must include a brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less, either as part of the form or as an addendum. Physicians must briefly synthesize the clinical information supporting the terminal diagnosis, and attest that they composed the narrative after reviewing the clinical information, and where applicable, examining the patient. The narrative must reflect the patient’s individual clinical circumstances. Narratives associated with the third and later benefit period must also include an explanation of why the clinical findings of the face-to-face encounter support a life expectancy of 6 months or less. (CMS Pub 100-02. Medicare Benefit Policy Manual, Chapter 9, Section 20.1)
For recertifications on or after January 1, 2011, a hospice physician or hospice nurse practitioner must have a face-to-face encounter with each hospice patient prior to the beginning of the patient’s third benefit period, and prior to each subsequent benefit period. (CMS Pub 100-02. Medicare Benefit Policy Manual, Chapter 9, Section 20.1)
A hospice physician or hospice nurse practitioner must have a face-to-face encounter with patients prior to the third benefit period recertification and each subsequent recertification. This encounter can occur up to 30 calendar days prior to recertification, and the hospice physician or nurse practitioner must attest that the visit occurred. The certification or recertification must include the benefit period dates to which it applies, and be signed and dated by the certifying or recertifying physician. Initial certifications may be prepared no more than 15 calendar days prior to the effective date of election. Recertifications may be prepared no more than 15 calendar days prior to the start of the subsequent benefit period. (CMS Pub 100-02, Medicare Benefit Policy Manual, Chapter 9, Section 20.1)
Hospice nurse practitioners may conduct face-to-face encounters as described in §20.1(5) as part of the certification process, but are still prohibited by statute from certifying the terminal illness. (CMS Pub 100-02. Medicare Benefit Policy Manual, Chapter 9, Section 20.1)
Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.
For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.
The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.
For claims submitted to the fiscal intermediary or Part A MAC:
The patient's principal diagnosis, i.e., the terminal illness, should be reported in Form Locator (FL) 67 of the UB-04. Additional or secondary diagnoses, i.e., comorbidities, may be reported in FLs 67A – 67Q.
Reasons for Denial
Medical review of records of hospice patients that do not document that patients meet the guidelines set forth in the LCD may result in denial of coverage unless other clinical circumstances reasonably predictive of a life expectancy of six months or less are provided.
The condition of some patients receiving hospice care may stabilize or improve during or due to that care, with the expectation that the stabilization or improvement will not be brief and temporary. In such circumstances, if the patient’s condition changes such that he or she no longer has a prognosis of life expectancy of six months or less, and that improvement can be expected to continue outside the hospice setting, then that patient should be discharged from hospice.
Documentation certifying terminal status must contain enough information to support terminal status upon review. Documentation of the applicable criteria listed under the “Indications” section of the LCD would meet this requirement. If other clinical indicators of decline not listed in tthe LCD form the basis for certifying terminal status, they should be documented as well. Recertification for hospice care requires the same clinical standards be met as for initial certification, but they need not be reiterated. They may be incorporated by specific reference as part (or all) of the indication for recertification.
Documentation should “paint a picture” for the reviewer to clearly see why the patient is appropriate for hospice care and the level of care provided, i.e., routine home, continuous home, inpatient respite, or general inpatient. The records should include observations and data, not merely conclusions. However, documentation should comport with normal clinical documentation practices. Unless elements in the record require explanation, such as a non-morbid diagnosis or indicators of likely greater than six month survival, as stated below, no extra or additional record entries should be needed to show hospice benefit eligibility.
The amount and detail of documentation will differ in different situations. A patient with metastatic small cell CA may be demonstrated to be hospice eligible with less documentation than one with chronic lung disease. Patients with chronic lung disease, long term survival in hospice, or apparent stability can still be eligible for hospice benefits, but sufficient justification for a less than six-month prognosis should appear in the record.
If the documentation includes any findings inconsistent with or tending to disprove a less than six-month prognosis, they should be answered or refuted by other entries, or specifically addressed and explained. Most facts and observations tending to suggest a greater than six month prognosis are predictable and apparent, such as a prolonged stay in hospice or a low immediate mortality diagnosis, as stated above. But specific entries can also call for an answer, such as an opinion by one team member or recovery of ADLs when they were part of the basis for the initial declaration of eligibility. Also the lack of certain elements such as a tissue diagnosis for cancer will not negate eligibility, but does necessitate other supportive documentation.
Documentation submitted may include information from periods of time outside the billing period currently under review. Include supporting events such as a change in the level of activities of daily living, recent hospitalizations, and the known date of death (if you are billing for a period of time prior to the billing period in which death occurred).
Submitted documentation should always include the admission assessment, as well as any evaluations and Interdisciplinary Group (IDG) discussions used for recertification. Records that show the progression of the patient’s illness are very helpful.
Documentation should support the level of care being provided to the patient during the time period under review, i.e. routine or continuous home or inpatient, respite or general. The reviewer should be able to easily identify the dates and times of changes in levels of care and the reason for the change.