Description
This review will determine if hospice Continuous Home Care services were reasonable and necessary to achieve palliation and management of the patient’s acute medical symptoms to maintain the terminally ill patient at home, based on the documentation in the medical record.
Affected Code(s)
REV Codes 0652
HCPCS G0299, G0300, G0156
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, § 1812(a)(4), (a)(5), and (d)- Scope of Benefits
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, § 1813(a)(4)(A)- Deductibles and Coinsurance
3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, § 1814(a)(7)- Conditions of and Limitations on Payment for Services
4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, § 1814(i)(1)(A)- Payment for Hospice Care
5. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, § 1815(a) and (e)(2)(D)- Payment to Providers of Services
6. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, § 1833(e)- Payment of Benefits
7. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, § 1861(u)- Provider of Services and (dd)- Hospice Care; Hospice Program
8. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, § 1862(a)(1)(A) and (a)(1)(C)- Exclusions from Coverage and Medicare as Secondary Payer
9. 42 CFR §405.929- Post-Payment Review
10. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
11. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
12. 42 CFR §405.986 - Good Cause for Reopening
13. 42 CFR § 411.15(k)(2) - Particular Services Excluded from Coverage
14. 42 CFR § 418.22 - Certification of terminal illness
15. 42 CFR § 418.24 - Election of hospice care
16. 42 CFR § 418.56 Condition of participation: Interdisciplinary group, care planning, and coordination of services
17. 42 CFR, § 418.204(a) Special coverage requirements; Periods of crisis.
18. 42 CFR, § 418.302 - Payment, Procedures for hospice care.
19. 42 CFR, § 424.5(a)(6) – Basic Conditions, Sufficient Information
20. Medicare General Information, Eligibility and Entitlement Manual, Chapter 4 - Physician Certification and Recertification of Services, § 60- Certification and Recertification by Physicians for Hospice Care
21. Medicare General Information, Eligibility and Entitlement Manual, Chapter 5 - Definitions, Section 60 - Hospice Defined
22. Medicare Benefit Policy Manual, Chapter 9, §§10- Requirements—General; 20- Certification and Election Requirements; 40- Benefit Coverage; 50- Limitation on Liability for Certain Hospice Coverage Denials; 80- Hospice Pre-election evaluation and counseling services.
23. Medicare Claims Processing Manual, Chapter 11- Processing Hospice Claims
24. Medicare Claims Processing Manual, Chapter 30 - Financial Liability Protections, §Section 50- Advance Beneficiary Notice of Non-coverage (ABN)
25. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §3.1- 3.6.6
26. CGS Administrators, LLC, LCD L34538- Hospice Determining Terminal Status; Effective 10/01/2015; Revised 08/07/2025.
27. National Government Services, Inc., LCD L33393 Hospice Determining Terminal Status; Effective 10/01/2015; Revised 11/14/2019.
28. National Government Services, Inc., LCA A52830 Billing and coding: Hospice: Determining Terminal Status; Effective 10/01/2015; Revised 11/14/2019
29. CMS Transmittal 13664, Change Request (CR) 14384 (effective 10/01/2025): Manual Updates Adding language to the Timing and Content of Certification, Revocation and Discharge Guidance, and Hospice Election
30. CMS, Hospice: CMS Flexibilities to Fight Covid-19, Revised 05/10/2023. Hospice: CMS Flexibilities to Fight COVID-19
31. HCPCS Level II Codebook