Understanding Palliative Care Coding Guidelines 2021 for Hospice Coverage

Hospice care offers a comprehensive and holistic approach to support individuals facing terminal illnesses, focusing on comfort and quality of life for both patients and their families. Moving away from curative treatments, hospice emphasizes palliative care, aiming to alleviate pain and manage symptoms effectively. Understanding the nuances of hospice coverage, particularly concerning palliative care coding guidelines in 2021, is crucial for both healthcare providers and patients seeking to navigate this essential benefit.

Medicare Part A provides hospice care benefits to eligible patients who meet specific criteria:

• Care must be provided by a Medicare-certified hospice agency.
• Both the patient’s attending physician (if applicable) and a hospice physician must certify the patient as terminally ill, with a life expectancy of 6 months or less if the illness progresses naturally.
• The patient must sign an election statement choosing the hospice benefit and waiving Medicare payments for curative treatments related to the terminal illness.

Upon certification, patients can elect hospice benefits for an initial period, followed by subsequent extension periods:

• Two 90-day periods, followed by an unlimited number of 60-day periods.
• For the third benefit period and all subsequent periods, recertification requires documentation of a face-to-face (FTF) encounter between a hospice physician or nurse practitioner and the patient. This FTF encounter must confirm the clinical findings that support a life expectancy of 6 months or less.

A crucial aspect of hospice care is the individualized written plan of care (POC). This POC is developed collaboratively by an interdisciplinary group, including the attending physician (if any), the patient or their representative, and the primary caregiver. It ensures that all care and services align with the patient’s specific needs and preferences.

Services Included Under the Hospice Benefit

The Medicare hospice benefit is designed to be comprehensive, covering a wide array of items and services aimed at minimizing pain, reducing disease severity, and managing the terminal illness and related conditions. These include:

• Physician and Nurse Practitioner Services: Services from hospice-employed physicians, nurse practitioners (NPs), and other physicians chosen by the patient to oversee and direct care.
• Nursing Care: Skilled nursing care to manage symptoms, administer medications, and provide overall medical support.
• Medical Equipment: Provision of necessary medical equipment such as wheelchairs, hospital beds, and oxygen equipment to enhance comfort and mobility at home.
• Medical Supplies: Coverage for medical supplies like bandages, catheters, and other necessary items for patient care.
• Medications for Pain and Symptom Management: Access to drugs specifically aimed at controlling pain and other distressing symptoms associated with the terminal illness.
• Hospice Aide and Homemaker Services: Assistance with personal care, daily living activities, and light household tasks provided by hospice aides and homemakers.
• Therapeutic Services: Physical therapy, occupational therapy, and speech-language pathology services to maintain functional abilities and address specific patient needs.
• Medical Social Services: Support from medical social workers to address emotional, social, and practical challenges faced by patients and families.
• Dietary Counseling: Nutritional guidance to ensure patients receive appropriate nutrition and manage any dietary concerns.
• Spiritual Counseling: Spiritual support and counseling services to address the patient’s and family’s spiritual and emotional needs.
• Grief and Loss Counseling: Individual and family grief counseling services provided both before and after the patient’s passing to support emotional well-being.
• Short-Term Inpatient Care: Short-term inpatient care for pain control, symptom management that cannot be managed at home, and respite care for caregivers.

Medicare retains the flexibility to cover other reasonable and necessary hospice services detailed in the patient’s Plan of Care, emphasizing the individualized nature of hospice support. The hospice program is responsible for offering and arranging these services to ensure comprehensive patient care.

Levels of Hospice Care and Reimbursement Considerations

Medicare typically reimburses hospice agencies at a daily rate for each day a patient is enrolled under the hospice benefit. This daily payment is consistent regardless of the intensity of services provided on any given day, and it covers the hospice’s operational costs for delivering services as outlined in the patient’s care plan. Payments are categorized into four distinct levels of hospice care, each reflecting different intensities of service and care settings:

1. Routine Home Care: This is the most common level, provided when a patient opts to receive hospice care in their home (which can include a private residence, assisted living facility, or skilled nursing facility) and does not require continuous home care. Routine home care is appropriate when the patient’s condition is stable and not in acute crisis.
2. Continuous Home Care: This level is designed for patients experiencing a brief period of crisis and requires intensive care to remain at home. It involves predominantly continuous nursing care in a home setting, supplemented by hospice aide and homemaker services as needed. Continuous home care is intended to stabilize the patient and avoid inpatient admission.
3. Inpatient Respite Care: This level offers temporary care in an approved inpatient facility, for up to 5 consecutive days, to provide respite for the patient’s primary caregiver. It allows caregivers to take a break while ensuring the patient continues to receive necessary hospice care in a safe environment.
4. General Inpatient Care: General inpatient care is provided in an inpatient facility for patients requiring pain control or acute symptom management that cannot be effectively managed in other settings. This level is for more complex care needs that necessitate a higher level of medical intervention.

Understanding these levels of care is intrinsically linked to Palliative Care Coding Guidelines 2021, as accurate coding ensures appropriate reimbursement for the intensity of services delivered at each level. Proper coding reflects the resources used and the acuity of patient needs, aligning with the principles of fair and accurate healthcare billing.

Hospice Coinsurance Responsibilities

While hospice care aims to minimize financial burdens during a challenging time, there are some coinsurance aspects patients should be aware of:

• Drugs and Biologicals Coinsurance: For palliative drugs and biologicals prescribed to manage pain and symptoms related to the terminal illness during routine home care or continuous home care, a coinsurance of 5% of the cost to the hospice applies for each prescription. However, this coinsurance is capped at a maximum of $5.00 per prescription. No coinsurance is applied during general inpatient care or respite care.
• Respite Care Coinsurance: For inpatient respite care, patients are responsible for a daily coinsurance amount, set at 5% of the Medicare payment for a respite care day. This coinsurance is also capped and cannot exceed the inpatient hospital deductible for the year in which the hospice coinsurance period began. This level of care inherently includes room and board costs.

These coinsurance structures are important for both patients and hospice providers to understand to ensure clarity on financial responsibilities and to facilitate accurate billing and coding practices in line with palliative care coding guidelines 2021.

Hospice Quality Reporting and Further Information

To ensure high standards of care and transparency, Medicare has established the Hospice Quality Reporting Program. This program mandates hospices to submit quality data, which is then used for public reporting and quality improvement initiatives.

For more detailed information regarding quality data submission and reporting requirements, resources are available on the Current Measures and Hospice Quality Reporting webpages provided by Medicare. These resources are invaluable for hospices aiming to stay compliant with reporting standards and continuously improve the quality of palliative care they deliver.