Local Coverage Article

Going Beyond Diagnosis®: Hospice Cardiopulmonary Conditions


Expand All | Collapse All

Contractor Information

Article Information

General Information

Article ID
Original ICD-9 Article ID
Article Title
Going Beyond Diagnosis®: Hospice Cardiopulmonary Conditions
Article Type
Original Effective Date
Revision Effective Date
Revision Ending Date
Retirement Date
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2022 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2022 American Dental Association. All rights reserved.

Copyright © 2022, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

Article Guidance

Article Text

Going Beyond Diagnosis®: Hospice Cardiopulmonary Conditions Local Coverage Determination (LCD)

The goal of the Hospice Cardiopulmonary Conditions LCD is to encourage the collection of more descriptive information to support predictions and decisions made by hospice organizations serving individuals with cardiopulmonary conditions.

The objectives for the LCD and its companion case scenario included:

• Incorporation of the concepts of the International Classification of Functioning Disability and Health (ICF) into the LCD.

• Providing a documentation framework to support the predictions and decisions required of hospice organizations.

• Demonstrating, via case scenario, a descriptive methodology that promotes communication and coordination across the continuum of care.

Palmetto Government Benefit Administrators (GBA's) approach to policy and education recognizes the importance of continuous quality improvement. As both Palmetto GBA and providers strive to make the best decisions possible, we are often faced with incomplete information despite voluminous documentation. Palmetto GBA’s recent policies and educational efforts have highlighted the fact that in order for information to be of value to health care organizations it must allow the end-user to make high quality predictions or decisions. In addition, the resulting outcomes, whether positive or negative, should be used to continuously improve our processes. Palmetto GBA has published several articles describing its approach. Please refer to the Palmetto GBA Web site articles titled:

Going Beyond Diagnosis®: Communicating Debility in Hospice & Palliative Care

Going Beyond Diagnosis®: Continuous Quality Improvement

Measurement is a critical piece of continuous quality improvement and requires the collection of relevant data. These data are then used to create information to continuously improve organizational processes, including facilitating semi-structured decisions such as admissions, level of care, re-certifications, and discharge. Whether you’re evaluating structure, process, outcomes, or patient/caregiver satisfaction, a standard language is essential when describing the health status and care needs of your patient population. That’s where the specificity inherent in the International Classification of Functioning, Disability and Health (ICF) taxonomy can help.

Health care organizations often evaluate the quality of their services by performing utilization review audits. These audits typically focus on high volume/high risk tasks that are critical to the organizational strategic plan. The evaluation often involves the selection of critical process and/or outcome measures. The selection of the most relevant process or outcome measures may be limited by incomplete clinical documentation. Palmetto GBA’s Going Beyond Diagnosis® educational initiative is focused on helping health care organizations identify, document, and communicate the unique health care needs of their patients in a systematic fashion - making it more likely that relevant pieces of data will be available to support their quality initiatives and Medicare reimbursement.

As stated in the Hospice Cardiopulmonary LCD “the identification of specific structural and/or functional impairments, together with any relevant activity limitations, should serve as the basis for palliative interventions and care-planning”. This supports the collection of more descriptive information by clarifying that the health status of individuals with cardiopulmonary conditions is not defined by ICD-10-CM codes, but rather is the result of complex interactions among the components, domains, and categories contained in the ICF. It also reinforces the experience of many hospice providers, namely that secondary and comorbid conditions are important considerations in addressing the service needs of individuals with non-cancer conditions, often impacting both prognosis and care plan.

Recognizing and documenting the impact of the aortic valve stenosis, in the Cardiopulmonary Going Beyond Diagnosis® case scenario, is key to making the best possible predictions and decisions. According to Carabello (N Engl J Med. 2002;346:677-682), the median survival for symptomatic individuals foregoing aortic valve replacement surgery depends on their presentation. The median survival, without surgery, is 5 years for the 35% of patients with aortic stenosis presenting with angina, 3 years for the 15% that present with syncope, and 2 years for the 50% presenting with dyspnea. In the absence of a comprehensive method for characterizing health status, clinicians serving this population of patients may recommend services that do not meet their patients’ care needs.

Palmetto GBA’s Medical Review Department has developed a Medical Review form, titled Going Beyond Diagnosis®: Using ICF Guidelines Worksheet, based on the concepts of the ICF. The form contains fields for the identification of relevant ICF components/categories, a description of how they manifest clinically, clinical interventions implemented to address the identified categories, and relevant outcomes. The first column of the Going Beyond Diagnosis®: Using ICF Guidelines Worksheet has been completed using the ICF codes associated with the most relevant ICF categories identified in the cardiopulmonary case scenario.

While Medicare claims do not use ICF codes for processing, and use of the ICF is not required of Medicare providers, Palmetto GBA has incorporated the ICF into its medical review process. Palmetto GBA medical reviewers use the Going Beyond Diagnosis®: Using ICF Guidelines Worksheet to adjudicate claims for complex clinical scenarios. This systematic process helps Palmetto GBA ensure that relevant pieces of information in the health record are identified and considered during the medical review process. Please share this article, and the Going Beyond Diagnosis®: Using ICF Guidelines Worksheet, with those members of your organization engaged in continuous quality improvement, it may help them improve your organization’s approach to evaluating and documenting the care provided to individuals with cardiopulmonary conditions.

Coding Information

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.


Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.




ICD-10-CM Codes that are Covered


ICD-10-CM Codes that are Not Covered


Revision History Information

Revision History DateRevision History NumberRevision History Explanation
05/24/2018 R3

Under Article Text title, added the verbiage “Local Coverage Determination” in front of the acronym “LCD”. Under Article Text, added the verbiage “Government Benefits Administrators” in front of the acronym “GBA’s” in the first sentence, third paragraph. Corrected punctuation errors throughout the policy.


06/03/2016 R2 Under Article Title deleted LCD from the title of the article. Under Article Guidance – Article Text added “LCD” and “is” and deleted “was” after verbiage “The goal of the Hospice Cardiopulmonary Conditions”, deleted “ICD-9-CM” and added “ICD-10-CM” to verbiage and added punctuation.
10/01/2015 R1 Under Article Text removed reference for Going Beyond Diagnosis®: ICD-9-CM 799.3 Debility, Unspecified (Revised July 2007), and Going Beyond Diagnosis®: Valuable Information as they are no longer available on the web. Added reference to Communicating Debility in Hospice & Palliative Care. Corrected the sentence in the 6th paragraph to read "....in the Cardiopulmonary Going Beyond Diagnosis® case scenario"... by removing the word "attached."

Associated Documents

Related Local Coverage Documents
L34548 - Hospice Cardiopulmonary Conditions
Related National Coverage Documents
Statutory Requirements URLs
Rules and Regulations URLs
CMS Manual Explanations URLs
Other URLs
Public Versions
Updated On Effective Dates Status
05/15/2018 05/24/2018 - N/A Currently in Effect You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.


  • Cardiopulmonary