This article outlines the coding guidelines and regulations that complement the Local Coverage Determination (LCD) for Hospice – Determining Terminal Status. It is crucial for hospice providers to understand these guidelines to ensure accurate billing and compliance with Medicare requirements.
National Coverage Provisions for Hospice Care
The landscape of hospice care underwent significant changes with the Affordable Care Act in March 2010. A key provision mandated face-to-face encounters between hospice physicians or nurse practitioners and Medicare hospice patients. This requirement is necessary prior to the 180th-day recertification and every subsequent recertification, with attestation of the encounter. These policies were implemented by CMS following the Home Health Prospective Payment System Rate Update for CY 2011 and the Changes in Certification Requirements for Home Health Agencies and Hospices Final Rule (75 FR 70372). This face-to-face encounter requirement became effective on January 1, 2011.
Furthermore, hospice certifications and recertifications necessitate a concise narrative explanation of the clinical findings supporting a life expectancy of 6 months or less. This narrative can be integrated into the certification form or provided as an addendum. Physicians are required to synthesize clinical information justifying the terminal diagnosis and affirm that the narrative was composed after reviewing clinical data and, when applicable, examining the patient. Crucially, the narrative must reflect the patient’s unique clinical circumstances. For the third and subsequent benefit periods, narratives must also explain how the face-to-face encounter’s clinical findings continue to 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 mandatory face-to-face encounter by a hospice physician or nurse practitioner is required before the start of the patient’s third benefit period and each subsequent benefit period. (CMS Pub 100-02. Medicare Benefit Policy Manual, Chapter 9, Section 20.1). This encounter can take place up to 30 calendar days before recertification. The hospice physician or nurse practitioner must attest to the visit’s occurrence. Certifications and recertifications must include the relevant benefit period dates and be signed and dated by the certifying or recertifying physician. Initial certifications can be prepared up to 15 calendar days before the election’s effective date, and recertifications can be prepared up to 15 calendar days before the subsequent benefit period begins. (CMS Pub 100-02, Medicare Benefit Policy Manual, Chapter 9, Section 20.1).
It is important to note that while hospice nurse practitioners can conduct these face-to-face encounters as part of the certification process (§20.1(5)), they are legally prohibited from certifying the terminal illness itself (CMS Pub 100-02. Medicare Benefit Policy Manual,* Chapter 9, Section 20.1).
Hospice Care Coding Information for Claims Processing
When it comes to Hospice Care Coding, procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Providers must always consult NCCI and OPPS guidelines before billing Medicare to ensure compliance and avoid claim rejections. For services that require a referring or ordering physician, it is mandatory to report the name and NPI of the referring/ordering physician on the claim. Failure to include this information can lead to claim denials or delays in processing.
Submitting a claim without a valid ICD-10-CM diagnosis code will result in the claim being returned to the provider as incomplete, as per Section 1833(e) of the Social Security Act. The diagnosis code(s) reported must accurately and specifically describe the patient’s condition for which hospice care services were rendered. For diagnostic tests performed within hospice care, if the test result is known, it should be reported. Otherwise, the symptoms that prompted the diagnostic test should be reported in the claim.
Specific guidelines apply for claims submitted to the fiscal intermediary or Part A MAC: The patient’s principal diagnosis, which is the terminal illness, should be reported in Form Locator (FL) 67 of the UB-04 claim form. Additional or secondary diagnoses, such as comorbidities that contribute to the patient’s condition, may be reported in FLs 67A through 67Q. Accurate reporting in these form locators is essential for proper claim processing and reimbursement in hospice care settings.
Reasons for Hospice Care Claim Denial
Medical reviews of hospice patient records are routinely conducted to ensure adherence to LCD guidelines. If the documentation fails to demonstrate that patients meet the criteria outlined in the LCD, coverage may be denied. This emphasizes the importance of thorough and accurate documentation to support the medical necessity of hospice care. However, it’s recognized that clinical circumstances not explicitly listed in the LCD may also reasonably predict a life expectancy of six months or less. In such cases, these circumstances must be clearly and comprehensively documented to justify hospice eligibility and prevent claim denials.
It’s also important to acknowledge that some patients receiving hospice care may experience stabilization or improvement in their condition due to the care provided. If this stabilization or improvement is not expected to be brief and temporary, and the patient’s prognosis changes such that they no longer have a life expectancy of six months or less, continued hospice care is no longer appropriate. Furthermore, if this improvement is expected to continue outside of the hospice setting, the patient should be discharged from hospice care. Continuing to bill for hospice services in such cases can lead to claim denials and potential audits.
Essential Documentation Guidelines for Hospice Services
Comprehensive documentation is paramount for certifying terminal status and ensuring appropriate hospice care coding and billing. The documentation must contain sufficient information to clearly support the patient’s terminal status upon medical review. Documenting the applicable criteria listed under the “Indications” section of the LCD is a direct way to meet this requirement. If clinical indicators of decline not listed in the LCD are the basis for certifying terminal status, these indicators must be thoroughly documented as well.
Recertification for hospice care requires the same clinical standards as the initial certification. However, it’s not necessary to reiterate all the initial clinical details. Instead, they can be incorporated by specific reference as part or all of the indication for recertification, streamlining the documentation process while maintaining compliance.
Documentation should effectively “paint a picture” for the reviewer, clearly illustrating why the patient is appropriate for hospice care and justifying the level of care provided (routine home, continuous home, inpatient respite, or general inpatient). Records should include objective observations and data, rather than just conclusions. While detailed, documentation should also align with standard clinical documentation practices. Unless specific elements in the record require further explanation—such as a non-morbid diagnosis or indicators suggesting a greater than six-month survival—no additional record entries should typically be needed to demonstrate hospice benefit eligibility.
The necessary amount and detail of documentation can vary based on individual patient situations. For instance, demonstrating hospice eligibility for a patient with metastatic small cell carcinoma may require less documentation compared to a patient with chronic lung disease. Patients with chronic conditions, those with long-term hospice stays, or those appearing stable can still be eligible for hospice benefits. However, in these cases, the record must include sufficient justification for a prognosis of less than six months to support hospice care coding and billing accuracy.
If the documentation includes any findings that are inconsistent with or tend to disprove a prognosis of less than six months, these inconsistencies must be addressed and refuted by other entries or specifically explained. Many factors suggesting a prognosis longer than six months are predictable, such as prolonged hospice stays or diagnoses not typically associated with immediate mortality. Specific entries, like a team member’s opinion or improvement in ADLs after they were initially used to determine eligibility, also require clarification. Similarly, the absence of certain elements, like a tissue diagnosis for cancer, does not automatically negate eligibility but necessitates additional supportive documentation to ensure accurate hospice care coding.
Submitted documentation may include relevant information from periods outside the current billing period under review. Pertinent supporting events can include changes in the level of activities of daily living, recent hospitalizations, and the known date of death, particularly if billing for a period before death. Crucially, submitted documentation should always include the initial admission assessment, as well as any evaluations and Interdisciplinary Group (IDG) discussions used for recertification. Records that demonstrate the progression of the patient’s illness over time are particularly helpful in justifying hospice care and supporting appropriate hospice care coding.
Finally, documentation should clearly support the level of care provided to the patient during the review period, whether routine or continuous home care, inpatient respite care, or general inpatient care. Reviewers should be able to easily identify the dates and times of changes in care levels and the clinical reasons for these changes, ensuring transparency and accountability in hospice care coding and billing practices.
