SUPERSEDED Local Coverage Determination (LCD)

Hospice Cardiopulmonary Conditions

L34548

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Proposed LCD
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Superseded
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Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L34548
Original ICD-9 LCD ID
Not Applicable
LCD Title
Hospice Cardiopulmonary Conditions
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 11/04/2021
Revision Ending Date
12/13/2023
Retirement Date
N/A
Notice Period Start Date
N/A
Notice Period End Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

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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.

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Issue

Issue Description

This LCD outlines limited coverage for this service with specific details under Coverage Indications, Limitations and/or Medical Necessity.

Issue - Explanation of Change Between Proposed LCD and Final LCD

CMS National Coverage Policy

Title XVIII of the Social Security Act, §1812(a)(4) states in lieu of certain other benefits, hospice care with respect to the individual during up to 2 periods of 90 days each with an 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, §1813(a)(4) addresses drugs and biologicals provided in a hospice program.

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

Title XVIII of the Social Security Act, §1861(dd) states the term "hospice care" means the services provided to a terminally ill individual.

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) constitutes personal comfort items (except, in the case of hospice care, as is otherwise permitted).

Title XVIII of the Social Security Act, §1862(a)(9) addresses expenses for custodial care (except, in the case of hospice care, as is otherwise permitted).

42 CFR, Part 418 Hospice Care

CMS Internet-Only Manual, Pub. 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 1, §10.1 Hospital Insurance (Part A) for Inpatient Hospital, Hospice, Home Health, and Skilled Nursing Facility (SNF) Services - A Brief Description

CMS Internet-Only Manual, Pub. 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4, §60 Certification and Recertification by Physicians for Hospice Care and §80 Summary Table for Certifications/Recertifications

CMS Internet-Only Manual, Pub. 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5, §60 Hospice Defined

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 9, §10 Requirements - General, §20.1 Timing and Content of Certification, §30 Coinsurance, §40 Benefit Coverage, §50 Limitation on Liability for Certain Hospice Coverage Denials, §60 Provision of Hospice Services to Medicare/Veteran's Eligible Beneficiaries, §70 Hospice Contracts with an Entity for Services not Considered Hospice Services, and §80 Hospice Pre-Election Evaluation and Counseling Services

Federal Register, Volume 70, No. 224, dated Tuesday, November 22, 2005, page 70537 

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Cardiopulmonary conditions are associated with impairments, activity limitations, and disability. Their impact on any given individual depends on the individual’s overall health status. Health status includes measures of functioning, physical illness, and mental well-being, as well as, environmental factors, such as the availability of palliative care services. The objective of this policy is to present a framework for identifying, documenting, and communicating the unique health care needs of individuals with cardiopulmonary conditions, and thus promote the overall goal of the appropriate care for every person, every time.

Cardiopulmonary conditions may support a prognosis of 6 months or less under many clinical scenarios. Medicare rules and regulations addressing hospice services require the documentation of sufficient “clinical information and other documentation” to support the certification of individuals as having a terminal illness with a life expectancy of 6 or fewer months, if the illness runs its normal course. The identification of specific structural/functional impairments, together with any relevant activity limitations, should serve as the basis for palliative interventions and care planning. Use of the International Classification of Functioning, Disability and Health (ICF) to help identify and document the unique service needs of individuals with cardiopulmonary conditions is suggested, but not required.

The health status changes associated with cardiopulmonary conditions can be characterized using categories contained in the ICF. The ICF contains domains (e.g., structures of cardiovascular and respiratory systems, functions of the cardiovascular and respiratory system, communication, mobility, and self-care) that allow for a comprehensive description of an individual’s health status and service needs. Information addressing relevant ICF categories, defined within each of these domains, should form the core of the clinical record and be incorporated into the care plan, as appropriate.

Additionally, the care plan may be impacted by relevant secondary and/or comorbid conditions. Secondary conditions are directly related to a primary condition. In the case of cardiopulmonary conditions, examples of secondary conditions could include delirium, pneumonia, stasis ulcers, and pressure ulcers. Comorbid conditions affecting beneficiaries with cardiopulmonary conditions are, by definition, distinct from the primary condition itself. An example of a comorbid condition would be End Stage Renal Disease (ESRD).

The important roles of secondary and comorbid conditions are described below, in order to facilitate their recognition and assist providers in documenting their impact. The identification and documentation of relevant secondary and comorbid conditions, together with the identification and description of associated structural/functional impairments, activity limitations, and environmental factors would help establish hospice eligibility and maintain a beneficiary-centered plan of care.

Secondary Conditions:

Cardiopulmonary conditions may be complicated by secondary conditions. The significance of a given secondary condition is best described by defining the structural/functional impairments together with any limitation in activity and restriction in participation related to the secondary condition. The occurrence of secondary conditions in beneficiaries with cardiopulmonary conditions results from the presence of impairments in such body functions as heart/respiratory rate and rhythm, contraction force of ventricular muscles, blood supply to the heart, sleep functions, and depth of respiration. These impairments contribute to the increased incidence of secondary conditions, such as delirium, pneumonia, stasis ulcers, and pressure ulcers observed in Medicare beneficiaries with cardiopulmonary conditions. Secondary conditions, themselves, may be associated with a new set of structural/functional impairments that may or may not respond/be amenable to treatment.

Ultimately, in order to support a hospice plan of care, the combined effects of the primary cardiopulmonary condition and any identified secondary condition(s) should be such that most beneficiaries with the identified impairments would have a prognosis of 6 months or less.

Comorbid Conditions:

The significance of a given comorbid condition is best described by defining the structural/functional impairments together with any limitation in activity and restriction in participation related to the comorbid condition. For example, a beneficiary with a primary cardiopulmonary condition and ESRD could have specific ESRD-related impairments of water, mineral and electrolyte balance functions coexisting with the cardiopulmonary impairments associated with the primary cardiopulmonary condition (e.g., Aortic Stenosis, Chronic Obstructive Pulmonary Disease, or Heart Failure).

Ultimately, in order to support a hospice plan of care, the combined effects of the primary cardiopulmonary condition and any identified comorbid condition(s), should be such that most beneficiaries with the identified impairments would have a prognosis of 6 months or less.

The documentation of structural/functional impairments and activity limitations facilitate the selection of the most appropriate intervention strategies (palliative/hospice versus long-term disease management), and provide objective criteria for determining the effects of such interventions. The documentation of these variables is thus essential in the determination of reasonable and necessary Medicare hospice services.

Summary of Evidence

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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

Documentation certifying terminal status must contain enough information to confirm terminal status upon review. Documentation meeting the criteria listed under the Coverage Indications, Limitations and/or Medical Necessity section of this Local Coverage Determination (LCD) would contribute to this requirement. Recertification for hospice care requires that the same standards be met, as for the initial certification.

Documentation should be legible and made available to the A/B (HHH) MAC upon request.

Sources of Information

N/A

Bibliography

Carabello BA. Clinical practice: Aortic stenosis. N Eng J Med. 2002;346(9):677-682.

Del Fabbro E, Dalal S, Bruera E. Symptom control in palliative care-part III: Dyspnea and delirium. J Palliat Med. 2006;9(2):422-36.

International Classification of Functioning, Disability and Health (ICF). Geneva: World Health Organization (WHO); 2001.

Rich MW. Heart failure in older adults. Med Clin North Amer. 2006;90(5):863-885.

Stuart B. Palliative care and hospice in advanced heart failure. J Palliat Med. 2007;10(1):210-228.

 

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
11/04/2021 R11

Under CMS National Coverage Policy updated regulation descriptions and section headings. Punctuation was corrected throughout the LCD.

  • Provider Education/Guidance
06/11/2020 R10

Under CMS National Coverage Policy, Title XVIII of the Social Security Act, §1814(i) addressing payment for hospice care, was moved to the related Billing and Coding: Hospice Cardiopulmonary Conditions A56610 article. Regulations unrelated to billing and coding were removed from related Billing and Coding: Hospice Cardiopulmonary Conditions A56610 article and moved to the CMS National Coverage Policy section of this LCD. Formatting, 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
10/10/2019 R9

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 Cardiopulmonary Conditions A56610 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
06/06/2019 R8

All coding located in the Coding Information section has been moved into the related Going Beyond Diagnosis®: Hospice Cardiopulmonary Conditions A50422 article and removed from the LCD. Under Bibliography changes were made to citations to reflect AMA citation guidelines. Formatting, 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
05/24/2018 R7

Under Associated Information in the first sentence added the verbiage “Local Coverage Determination” in front of the acronym “LCD”. Under Sources of Information, revisions were made to reflect AMA citation guidelines.

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. 

 

  • Risk Identified by a Zone Program Integrity Contractor (ZPIC)
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
06/03/2016 R5 Under CMS National Coverage Policy Change Request 9369, Transmittal 3378 was deleted as this was manualized and is now found in the following manual citations: CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 10, §40.2 and CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 11, §§30.2, 30.2.2, 30.3. Under Coverage Indications, Limitations and/or Medical Necessity added “and” before mental wellbeing to the first paragraph verbiage. Under Associated Information- Documentation Requirements bolded and italicized Coverage Indications, Limitations and/or Medical Necessity, added an “A” initial to author’s name and corrected punctuation.
  • 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 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/or revenue code removal)
10/01/2015 R2 Under Coverage Indications, Limitations and/or Medical Necessity in the first paragraph, third sentence add “measures of functioning, physical illness, mental wellbeing, as well as,” to clarify health status, and changed the word “right” to appropriate in the last sentence.
Under ICD-10 Codes that support Medical Necessity added the statement “While there are no specific ICD-10-CM codes for end stage cardiopulmonary conditions, the ICD-10-CM code describing the most relevant illness, disorder, or injury contributing to the prognosis of six months or less should be coded.”
Under Associated Information corrected the sentence “….Indications and Limitations of Coverage….” To read “…Coverage Indications, Limitations and/or Medical Necessity…”.
Under Sources of Information and Basis for Decision corrected all sources to AMA formatting.
  • Provider Education/Guidance
  • Other (Annual Validation)
10/01/2015 R1 Under CMS National Coverage Policy added Hospice Care to 42 CFR Chapter IV, Part 41.
Under Coverage Indications, Limitations and /or Medical Necessity removed “Health status mediates the much studied relationship between ICD-9-CM diagnosis and care outcomes.”
  • Other (Maintenance (Annual Review))
N/A

Associated Documents

Attachments
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Related National Coverage Documents
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Public Versions
Updated On Effective Dates Status
12/08/2023 12/14/2023 - N/A Currently in Effect View
10/29/2021 11/04/2021 - 12/13/2023 Superseded You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • Hospice
  • Cardiopulmonary Conditions

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