Local Coverage Determination (LCD)

Hospice - Liver Disease

L34544

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Proposed LCD
Proposed LCDs are works in progress that are available on the Medicare Coverage Database site for public review. Proposed LCDs are not necessarily a reflection of the current policies or practices of the contractor.

Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L34544
Original ICD-9 LCD ID
Not Applicable
LCD Title
Hospice - Liver Disease
Proposed LCD in Comment Period
N/A
Source Proposed LCD
N/A
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 10/24/2019
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
N/A
Notice Period End Date
N/A
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Issue

Issue Description
Issue - Explanation of Change Between Proposed LCD and Final LCD

CMS National Coverage Policy

Title XVIII of the Social Security Act, §1861 (dd)(1) the term "hospice care" means the services provided to a hospice patient

Title XVIII of the Social Security Act, §1862 (a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member

Title XVIII of the Social Security Act, §1862 (a)(6) items and services which constitute personal comfort items (except, in the case of hospice care, as it otherwise permitted)

Title XVIII of the Social Security Act, §1862 (a)(9) items and services where such expenses are for custodial care (except in the case of hospice care, as is otherwise permitted)

Title XVIII of the Social Security Act, §1812 (a)(4) in lieu of certain benefits, hospice care with respect to the individual during up to two periods of 90 days each and unlimited number of subsequent periods of 60 days each with respect to which the individual makes an election

Title XVIII of the Social Security Act, §1814 (a)(7)(A)(i) certifying the patient for hospice

42 CFR Part 418 Hospice Care

CMS Internet-Only Manual, Pub 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4, §60

CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 9, §§10, 20.1, 20.2, 20.2.1, 40-40.5, and 80

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Medicare coverage of hospice care depends upon a physician’s certification of an individual’s prognosis of a life expectancy of six months or less if the terminal illness runs its normal course. Recognizing that determination of life expectancy during the course of a terminal illness is difficult, this A/B Medicare Administrative Contractor (MAC)(HHH) has established medical criteria for determining prognosis for non-cancer diagnoses. These criteria form a reasonable approach to the determination of life expectancy based on available research, and may be revised as more research is available. Coverage of hospice care for patients not meeting the criteria in this policy may be denied. However, some patients may not meet the criteria, yet still be appropriate for hospice care because of other comorbidities or rapid decline. Coverage for these patients may be approved on an individual consideration basis.

Patients will be considered to be in the terminal stage of liver disease (life expectancy of 6 months or less) if they meet the following criteria (1 and 2 must be present; factors from 3 will lend supporting documentation):

1. The patient should show both a and b:

    a. Prothrombin time prolonged more than 5 seconds over control, or International Normalized Ratio (INR)> 1.5

        b. Serum albumin <2.5 gm/dl

 2. End stage liver disease is present and the patient shows at least one of the following:

       a. Ascites, refractory to treatment or patient non-compliance

       b. Spontaneous bacterial peritonitis

       c. Hepatorenal syndrome (elevated creatinine and blood urea nitrogen (BUN) with oliguria (<400 ml/day) urine and sodium concentration <10 mEq/l)

       d. Hepatic encephalopathy, refractory to treatment, or patient non-compliance

       e. Recurrent variceal bleeding, despite intensive therapy

 3. Documentation of the following factors will support eligibility for hospice care:

       a. Progressive malnutrition

       b. Muscle wasting with reduced strength and endurance

       c. Continued active alcoholism (> 80 gm ethanol/day)

       d. Hepatocellular carcinoma

       e. Hepatitis B virus surface antigen (HBsAg)positivity

       f. Hepatitis C refractory to interferon treatment.

Patients awaiting liver transplant who otherwise fit the above criteria may be certified for the Medicare hospice benefit, but if a donor organ is procured, the patient must be discharged from hospice.

Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A

Proposed Process Information

Synopsis of Changes
Changes Fields Changed
N/A
Associated Information
Sources of Information
Bibliography
Open Meetings
Meeting Date Meeting States Meeting Information
N/A
Contractor Advisory Committee (CAC) Meetings
Meeting Date Meeting States Meeting Information
N/A
MAC Meeting Information URLs
N/A
Proposed LCD Posting Date
Comment Period Start Date
Comment Period End Date
Reason for Proposed LCD
Requestor Information
This request was MAC initiated.
Requestor Name Requestor Letter
N/A
Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code Description
N/A

Revenue Codes

Code Description
N/A

CPT/HCPCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

N/A

Additional ICD-10 Information

General Information

Associated Information

Documentation Requirements

1. Documentation supporting medical necessity should be legible, maintained in the patient’s medical record, and must be made available to the A/B MAC (HHH) upon request.

2. Documentation certifying terminal status must contain enough information to confirm terminal status upon review. Documentation meeting the criteria outlined in the Coverage Indications, Limitations and/or Medical Necessity section of this Local Coverage Determination (LCD) would meet this requirement.

3. If the patient does not meet the criteria outlined in the Coverage Indications, Limitations and/or Medical Necessity section of this policy, yet is deemed appropriate for hospice care, sufficient documentation of the patient’s condition that justifies terminal status, in the absence of meeting the above criteria, would be necessary.

4. Re-certification for hospice care requires that the same standards be met as for the initial certification.

Sources of Information
N/A
Bibliography

Medical guidelines for determining prognosis in selected non-cancer diseases. The National Hospice Organization. Hosp Jour.1996;11(2):47-63.

 

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
10/24/2019 R11

This LCD is being revised in order to adhere to CMS requirements per Chapter 13, Section 13.5.1 of the Program Integrity Manual, to remove all coding from LCDs. There has been no change in coverage with this LCD revision. Regulations regarding billing and coding were removed from the CMS National Coverage Policy section of this LCD and placed in the related Billing and Coding: Hospice - Liver Disease A56669 Article.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Provider Education/Guidance
07/11/2019 R10

All coding located in the Coding Information section has been moved into the related Billing and Coding: Hospice - Liver Disease A56669 article and removed from the LCD.

Punctuation and typographical errors were corrected throughout the LCD.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Provider Education/Guidance
05/02/2019 R9

Under Bibliography “Consultants and other Medicare Medical Directors” was removed. Formatting and typographical errors were corrected throughout the LCD. Acronyms were inserted where appropriate throughout the LCD.

  • Provider Education/Guidance
10/01/2018 R8

Under ICD-10 Codes that Support Medical Necessity: Group 1 added ICD-10 code K83.01. This revision is due to the 2018 Annual ICD-10 Code Update and is effective on October 1, 2018.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Revisions Due To ICD-10-CM Code Changes
06/07/2018 R7

Under Coverage Indications, Limitations and/or Medical Necessity 1.b. added “<2.5 gm/dl” after “Serum albumin”, 2.c. revised the verbiage to read “hepatorenal syndrome (elevated creatinine and blood urea nitrogen (BUN) with oliguria (<400ml/day) and urine sodium concentration <10 mEq/l)” and 3.e. added the verbiage “Hepatitis B virus surface antigen” in front of the acronym “HBsAG” and removed the verbiage “Hepatitis B”. Under Associated Information – Documentation Requirements  2. removed the word “policy” and replaced with “Local Coverage Determination (LCD)”, 3.added the word “above” in front of the word “criteria” and 4. added the word “the” in front of the word “initial”.  Formatting, punctuation and typographical errors were corrected throughout the policy.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

 

  • Provider Education/Guidance
  • Public Education/Guidance
01/01/2017 R6 Under CPT/HCPCS Codes the description was revised for HCPCS code G0300. This revision is due to the 2017 Annual CPT/HCPCS Code Update and becomes effective 1/1/17.
  • Provider Education/Guidance
  • Revisions Due To CPT/HCPCS Code Changes
07/28/2016 R5 Under CMS National Coverage Policy in the Title XVIII of the Social Security Act, §1862 (a)(6) and Title XVIII of the Social Security Act, §1862 (a)(9) the verbiage “under paragraph (1)(c)” was deleted and punctuation corrected. The verbiage in the Title XVIII of the Social Security Act, §1812 (a)(4) was revised to read “in lieu of certain benefits, hospice care with respect to the individual during up to two periods of 90 days each and unlimited number of subsequent periods of 60 days each with respect to which the individual makes an election ”. Change Request 9369 was deleted as the information has been manualized and the following reference was added: CMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 11, §§30.2, 30.2.2, and 30.3. Under Associated Information – Documentation Requirements removed the word “the” in front of the verbiage “medical necessity” in the first sentence.
  • Provider Education/Guidance
  • Typographical Error
01/01/2016 R4 Under CMS National Coverage Policy section added CMS Internet-Only Manual, Pub 100-04 Medicare Claims Processing Manual, Change Request 9369, Transmittal 3378 dated October 16, 2015. Under CPT/HCPCS Codes section added HCPCS codes G0299 and G0300.
  • Revisions Due To CPT/HCPCS Code Changes
10/01/2015 R3 Under CMS National Coverage Policy added reference to CMS IOM 100-02, Chapter 9 sections 40.1-40.5 all inclusive.
Under Coverage Indications, Limitations and/or Medical Necessity made a few punctuation and spacing corrections.
Under Sources of Information and Basis for Decision corrected source title.
  • Provider Education/Guidance
  • Typographical Error
  • Other (Annual Validation)
10/01/2015 R2 Per CMS Internet-Only Manual, Pub 100-08, Medicare Program Integrity Manual, Chapter 13, §13.1.3 LCDs consist of only “reasonable and necessary” information. All bill type and revenue codes have been removed.
  • Other (Bill type and revenue code removal)
10/01/2015 R1 Under CMS National Coverage Policy added Hospice Care to 42 CFR, Part 418. Under Sources of Information and Basis for Decision updated reference to follow AMA format.
  • Provider Education/Guidance
  • Other (Maintenance
    Annual Validation)
N/A

Associated Documents

Attachments
N/A
Related National Coverage Documents
N/A
Public Versions
Updated On Effective Dates Status
10/18/2019 10/24/2019 - N/A Currently in Effect You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • Hospice Liver Disease
  • Liver Disease
  • Hospice

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