CMS Palliative Care Coding Guidelines 2021: A Comprehensive Guide

Hospice care, a vital program for those facing terminal illness, prioritizes comfort and quality of life through palliative care. For Medicare Fee-for-Service (FFS) beneficiaries, understanding the nuances of hospice coverage, especially in line with Cms Palliative Care Coding Guidelines 2021, is crucial. This guide aims to clarify these aspects, ensuring patients and their families can navigate hospice benefits effectively.

Understanding Medicare Hospice Coverage

Medicare Part A offers robust hospice care benefits, designed to provide comprehensive and holistic support for terminally ill patients and their families. Hospice shifts the focus from curative treatments to palliative care, emphasizing pain relief and symptom management. This approach ensures patient comfort and dignity in their final months.

To be eligible for Medicare hospice benefits, patients must meet specific criteria:

Medicare-Certified Hospice: Care must be provided by a hospice agency certified by Medicare.
Terminal Illness Certification: Both the patient’s attending physician (if they have one) and the hospice physician must certify the patient as terminally ill, with a prognosis of 6 months or less if the illness follows its natural course.
Hospice Benefit Election: Patients must sign an election statement to choose the hospice benefit, thereby waiving Medicare payments for curative treatments related to their terminal illness.

Alt: Hospice care emblem representing palliative comfort and enhanced life quality.

Upon certification, patients can elect hospice benefits for specific periods:

Initial Coverage: Two 90-day periods.
Subsequent Coverage: Followed by an unlimited number of 60-day periods.
Face-to-Face Encounters: After the initial two 90-day periods, recertification for the third and all subsequent benefit periods requires documentation of a face-to-face (FTF) encounter between a hospice physician or nurse practitioner and the patient. This FTF encounter must validate the clinical findings supporting a life expectancy of 6 months or less, aligning with CMS palliative care coding guidelines 2021 for recertification.

A crucial element of hospice care is the individualized written plan of care (POC). This POC, tailored to meet the patient’s specific needs, is developed by the hospice interdisciplinary group in collaboration with the attending physician (if any), the patient or their representative, and the primary caregiver. This collaborative approach ensures that the care plan is comprehensive and patient-centered, reflecting the principles of palliative care and adhering to relevant coding guidelines for service documentation.

Services Included in the Hospice Benefit

The Medicare hospice benefit is comprehensive, covering a wide array of items and services aimed at alleviating pain, managing symptoms, and supporting patients and families facing terminal illness. These services, essential components of palliative care, are detailed in CMS palliative care coding guidelines 2021 to ensure appropriate billing and service provision.

The included services are:

Physician and Nurse Practitioner Services: Services from hospice-employed physicians, nurse practitioners (NPs), and other physicians chosen by the patient, focusing on palliative care management.
Nursing Care: Skilled nursing care to manage symptoms, administer medications, and provide overall medical support.
Medical Equipment and Supplies: Provision of necessary medical equipment (e.g., wheelchairs, hospital beds) and medical supplies (e.g., bandages, catheters) related to the terminal illness.
Medications for Pain and Symptom Management: Drugs specifically for pain and symptom control, a cornerstone of palliative care in hospice.
Hospice Aide and Homemaker Services: Assistance with personal care and household tasks to support patient comfort and daily living.
Therapy Services: Physical therapy, occupational therapy, and speech-language pathology services to maintain or improve patient function and quality of life.
Medical Social Services: Support from medical social workers to address emotional, social, and practical needs of patients and families.
Dietary Counseling: Nutritional guidance tailored to the patient’s needs and preferences.
Spiritual Counseling: Spiritual support services to address the patient’s and family’s spiritual and emotional concerns.
Grief and Loss Counseling: Individual and family counseling both before and after the patient’s death, aiding in coping with loss and bereavement.
Short-Term Inpatient Care: Inpatient care for pain control and symptom management, as well as respite care for caregivers.

Medicare may also cover other services deemed reasonable and necessary within the patient’s POC. The hospice program is responsible for offering and arranging these services, ensuring comprehensive palliative care as outlined in CMS guidelines.

Alt: Diverse healthcare professionals providing Medicare hospice benefit services.

Levels of Hospice Care and Reimbursement

Medicare typically reimburses hospice agencies at a daily rate for each enrolled patient, regardless of the specific services provided on any given day. These daily rates are designed to cover the hospice’s costs for delivering services detailed in the patient’s care plan. Understanding these levels is important for both service delivery and adherence to CMS palliative care coding guidelines 2021 for billing.

Medicare payments are categorized into four levels of hospice care:

Routine Home Care: This is the most common level, provided when a patient chooses to receive hospice care at home (which can include a private residence, skilled nursing facility, or assisted living facility) and is not in need of continuous home care. Routine home care is appropriate when the patient’s condition is stable and not in crisis.
Continuous Home Care: This level is for patients experiencing a brief period of crisis who require intensive care to remain at home. It mandates that care is primarily nursing care provided on a continuous basis in the home setting (not an inpatient facility). Hospice aide and homemaker services can supplement continuous nursing care.
Inpatient Respite Care: Designed to offer temporary relief to caregivers, inpatient respite care allows patients to receive care in an approved inpatient facility for up to 5 consecutive days. This provides caregivers with a necessary break while ensuring the patient continues to receive appropriate hospice care.
General Inpatient Care: This level is for patients requiring inpatient care in a facility for pain control or acute or chronic symptom management that cannot be effectively managed in other settings. General inpatient care is intended for more acute needs that necessitate a higher level of medical intervention.

Hospice Coinsurance Responsibilities

While Medicare covers a significant portion of hospice costs, patients may be responsible for certain coinsurance amounts. These are important for understanding the patient’s financial obligations under Medicare hospice benefits and are relevant to accurate billing and coding practices within CMS guidelines.

Patient coinsurance responsibilities include:

Drugs and Biologicals Coinsurance: For palliative drugs and biologicals related to the terminal illness and symptom management, patients may owe a coinsurance payment for each prescription during routine home care or continuous home care. This coinsurance is typically 5% of the drug cost to the hospice, with a maximum of $5.00 per prescription, as per the hospice’s drug copayment schedule. No coinsurance applies 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 cannot exceed the inpatient hospital deductible for the year the hospice coinsurance period began and includes room and board costs.

Hospice Quality Reporting Program

To ensure high-quality care and accountability, hospices participate in the Hospice Quality Reporting Program. This program focuses on data submission and reporting requirements, contributing to the overall quality and transparency of hospice services. While not directly related to CMS palliative care coding guidelines 2021, it reflects CMS’s broader commitment to quality in hospice and palliative care.

For detailed information on quality data submission and reporting requirements, resources are available on the CMS website, including the Current Measures and Hospice Quality Reporting webpages. These resources provide essential information for hospices to maintain compliance and continuously improve the quality of care they provide.

By understanding these key aspects of Medicare hospice coverage, including eligibility, covered services, levels of care, and coinsurance, patients and families can better access and utilize these valuable benefits. Furthermore, healthcare providers can ensure they are adhering to best practices and relevant guidelines, including CMS palliative care coding guidelines 2021, in delivering high-quality palliative care within the hospice setting.