Hospice care provides crucial support and comfort for individuals facing a terminal illness. Navigating the regulations and coding requirements for hospice services, particularly within the Medicare system, is essential for healthcare providers. This guide outlines the key coding and documentation guidelines for hospice care, ensuring compliance and optimal patient care.
National Coverage Provisions for Hospice Care
The landscape of hospice care within Medicare has been shaped by key legislative changes, notably the Affordable Care Act of 2010. This legislation mandated face-to-face encounters between a hospice physician or nurse practitioner and the patient before the 180th-day recertification and for every subsequent recertification. Implemented in 2011, this requirement emphasizes direct patient assessment to ensure ongoing eligibility for hospice benefits.
Furthermore, Medicare mandates specific narrative documentation within hospice certifications and recertifications. A concise narrative explaining the clinical findings supporting a life expectancy of six months or less must be included, either directly in the certification form or as an addendum. Physicians are required to synthesize clinical information, affirming they composed the narrative after reviewing patient data and, when appropriate, examining the patient. This narrative must be personalized to reflect the patient’s unique clinical circumstances. For the third and subsequent benefit periods, narratives must also justify why the face-to-face encounter findings still support a prognosis of six months or less.
For recertifications occurring on or after January 1, 2011, a face-to-face encounter is mandatory before the start of the patient’s third benefit period and each subsequent period. This encounter, conducted by a hospice physician or nurse practitioner, can take place up to 30 days prior to recertification. The certification or recertification must clearly state the benefit period dates, and be signed and dated by the physician. Initial certifications can be prepared up to 15 days before the election’s effective date, and recertifications up to 15 days before the subsequent benefit period begins. While hospice nurse practitioners can conduct these face-to-face encounters, statutory regulations still prohibit them from formally certifying terminal illness.
Essential Coding Information for Hospice Billing
Accurate coding is paramount for hospice billing compliance. Procedure codes utilized in hospice care may be subject to National Correct Coding Initiative (NCCI) edits or Outpatient Prospective Payment System (OPPS) packaging edits. Providers must consult NCCI and OPPS guidelines before submitting claims to Medicare to avoid errors and ensure proper reimbursement.
When services necessitate a referring or ordering physician, the claim must include the name and National Provider Identifier (NPI) of the relevant physician. Claims submitted without a valid ICD-10-CM diagnosis code will be deemed incomplete and returned to the provider, as per Section 1833(e) of the Social Security Act.
The diagnosis code(s) reported should most accurately reflect the patient’s condition for which hospice services are being provided. For diagnostic tests conducted within hospice care, if the result is known, it should be reported. Otherwise, the symptoms that prompted the test should be documented. For claims submitted to fiscal intermediaries or Part A Medicare Administrative Contractors (MACs), the patient’s principal diagnosis—the terminal illness—should be reported in Form Locator (FL) 67 of the UB-04 form. Additional or secondary diagnoses, such as comorbidities, can be reported in FLs 67A through 67Q.
Documentation Guidelines to Certify Terminal Status
Comprehensive documentation is critical to support a patient’s terminal status and eligibility for hospice care. Documentation should contain sufficient information to justify terminal status upon medical review. Documenting the criteria outlined in the Local Coverage Determination (LCD) for Hospice is a direct way to meet this requirement. If clinical indicators of decline not specified in the LCD form the basis for certifying terminal status, these must also be thoroughly documented. Recertification documentation requires meeting the same clinical standards as initial certification, though these standards do not need to be reiterated if they are specifically referenced from the initial certification.
Effective documentation should vividly illustrate why hospice care is appropriate for the patient and justify the level of care provided, whether it is routine home care, continuous home care, inpatient respite care, or general inpatient care. Records should emphasize objective observations and data rather than subjective conclusions. While adhering to standard clinical documentation practices, it’s important to provide clear justification for hospice eligibility. Unless specific elements require explanation—such as non-morbid diagnoses or indicators suggesting a prognosis longer than six months—no extra documentation should be needed to demonstrate hospice benefit eligibility.
The necessary amount and detail of documentation will vary depending on the patient’s condition. For example, a patient with metastatic small cell carcinoma may require less extensive documentation compared to a patient with chronic lung disease. Patients with chronic conditions, those with extended hospice stays, or those exhibiting apparent stability can still be eligible for hospice benefits, but the record must contain sufficient justification for a prognosis of less than six months.
Any findings within the documentation that are inconsistent with or seem to contradict a prognosis of less than six months must be addressed and explained or refuted by other entries in the record. Predictable factors that might suggest a longer prognosis, such as prolonged hospice stays or diagnoses with low immediate mortality, should be anticipated and justified. Specific entries, like a team member’s opinion or improvement in Activities of Daily Living (ADLs) when ADL decline was part of the initial eligibility basis, 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.
Submitted documentation can include relevant information from periods outside the current billing period under review. Supporting events like changes in ADL levels, recent hospitalizations, and the date of death (if billing for a period preceding death) should be included. Crucially, submitted documentation should always include the initial admission assessment and any evaluations and Interdisciplinary Group (IDG) discussions used for recertification. Records that illustrate the progression of the patient’s illness are particularly valuable.
Finally, documentation must substantiate the level of care provided during the review period. Reviewers should be able to easily discern the dates and times of changes in care levels and the reasons for these changes.
Reasons for Hospice Care Denial and Discharge Considerations
Medical reviews of hospice patient records that do not adequately document that patients meet the established guidelines may lead to coverage denial. This underscores the importance of thorough and accurate documentation. Denial can occur if records fail to demonstrate that the patient’s condition meets the criteria for a life expectancy of six months or less, unless other compelling clinical circumstances indicative of such a prognosis are provided.
Conversely, some patients receiving hospice care may experience stabilization or improvement in their condition, sometimes due to the care itself. If this stabilization or improvement is not expected to be temporary and the patient no longer has a prognosis of life expectancy of six months or less, discharge from hospice care is appropriate. This ensures that hospice services are reserved for those who continue to meet the terminal illness criteria.
In conclusion, a strong understanding of coding guidelines and comprehensive documentation practices are vital for hospice providers. Adhering to these guidelines ensures compliance, facilitates appropriate reimbursement, and, most importantly, supports the delivery of quality, compassionate care to patients and their families during end-of-life journeys.
