Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Hospice Care
Policy #:MA02.001a

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

Medicare Advantage covers a one-time hospice consultation. Once a member elects hospice benefits, all Medicare-covered benefits and services unrelated to the terminal condition while an individual is in hospice care, are reimbursed by Original Medicare. Providers are to bill Original Medicare for hospice care as well as those services unrelated to the terminal condition while an individual is in hospice care. The Company is not responsible for the reimbursement of hospice services, or services unrelated to the terminal illness while the individual is in hospice care.

For non-Medicare covered services offered under the member's Medicare Advantage plan (e.g., dental, vision), providers are to submit the claim to the Company's Medicare Advantage plan.

For individuals who elect to end their hospice care, reimbursement of services will remain with Original Medicare until the first day of the month following the election to end hospice then revert to the member's Medicare Advantage plan.
Policy Guidelines

This policy is consistent with Medicare's coverage determination. The Company's reimbursement methodology may differ from Medicare.

BENEFIT APPLICATION

For hospice services that are covered by Medicare, payment is made by Original Medicare

Refer to the Evidence of Coverage for information regarding in-network and out-of-network cost-sharing.

Individuals may choose to terminate their hospice services at any time without impact on other benefits.

Description

Hospice care is care that provides comfort, including pain relief, physical care, counseling, and other services, that will help an individual cope with a terminal illness. Hospice care aims to manage the individual's illness and pain, but does not treat the underlying terminal illness. When an individual elects to receive hospice care, treatment (other than palliative treatment) prescribed for the terminal illness is no longer performed. However, the individual may elect to revoke the election of hospice care at any time and resume treatment of his/her illness.

A hospice provider is an individual or group of providers primarily engaged in providing pain relief, symptom management, and supportive services to a terminally ill individual with an anticipated life expectancy of six months or less. In addition, respite care may be offered. Respite care is a service that provides care for the terminally ill in order to relieve the individual's family and/or primary caregiver(s) for a brief time.


HOSPICE LEVELS OF CARE
  • Routine home care: The most common level of hospice care is provided at the routine home care level. Routine home care is provided where an individual resides. This may be a home, a skilled nursing facility, or an assisted living facility. It is the level of care provided when the individual is not in crisis. Care provided is dictated by the hospice plan of care, which is developed by the hospice team in partnership with the individual's attending professional provider (doctor of medicine or osteopathy [MD/DO] or a nurse practitioner [NP]). Services related to the palliation or management of the individual's terminal illness that are part of the hospice plan of care may include, but are not limited to, scheduled visits from nurses, aides, and social workers on an intermittent basis in a home setting; palliative medications; physical or occupational therapy, or speech-language pathology; medical supplies and durable medical equipment.
  • Continuous home care: Occurs where an individual resides, during brief periods of medical crisis. A period of crisis is a period when an individual requires continuous care which is predominantly nursing care to achieve palliation or management of acute medical symptoms. At least 8 hours of every 24 hours of care must be skilled nursing care. Home health aide services may also be provided to supplement the nursing care. Continuous home hospice care does not include private duty nursing services when hospice care benefits are obtained/elected/selected. An individual will not have the option to simultaneously use/obtain any separate benefits that may exist under his/her plan for private duty nursing care.
  • General inpatient care (nonrespite): Occurs in an inpatient facility. If an individual's care cannot be feasibly managed in other settings due to conditions such as but not limited to uncontrollable pain, respiratory distress, intractable nausea/vomiting, the individual will be moved to an inpatient facility until the individual’s condition is stabilized. This level of hospice care generally takes place in an acute care hospital or hospice facility depending on the individual's care requirements.
  • Inpatient respite care: Is provided in an inpatient facility, generally a skilled nursing facility (SNF). Respite care is short-term inpatient care provided to the individual only when necessary to relieve the family members or other persons who normally care for the individual at home.

References

Center for Medicare Advocacy (CMA). Hospice. [CMA Web site]. N.D. Available at: http://www.medicareadvocacy.org/medicare-info/medicare-hospice-benefit/. Accessed May 14, 2018.

National Association for Homecare and Hospice (NAHC). Hospice in-patient level of care and continuous home care. [NAHC Web site]. Available at: http://www.nahc.org/assets/1/7/am13-617.pdf. Accessed May 14, 2018.

Centers for Medicare & Medicaid Services (CMS). CMS Manual System. Transmittal 188. Pub 100-02: Medicare Benefit Policy. Updates and clarifications to the hospice policy chapter of the benefit policy manual. [CMS Web site]. 08/04/14. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R188BP.pdf. Accessed May 14, 2018.

Centers for Medicare & Medicaid Services (CMS). CMS Manual System. Transmittal 209. Pub 100-02: Medicare Benefit Policy. Updates on Hospice Election Form, Revocation, and Attending Physician. [CMS Web site]. 10/01/2014. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R209BP.pdf. Accessed May 14, 2018.

Centers for Medicare & Medicaid Services (CMS). Hospice. [CMS Web site]. Modified 03/07/2018. Available at: http://www.cms.gov/Hospice/. Accessed May 14, 2018.

Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual. Chapter 11: Processing hospice claims. [CMS Web site]. 12/01/17. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c11.pdf. Accessed May 14, 2018.

Centers for Medicare & Medicaid Services (CMS). Medicare Benefit Policy Manual. Publication 100-02. Chapter 9: Coverage of hospice services under hospital insurance. [CMS Web site]. 05/08/15. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c09.pdf. Accessed May 14, 2018.

Centers for Medicare & Medicaid Services (CMS). Medicare Hospice Benefits. [CMS Web site]. Revised March 2018. Available at: https://www.medicare.gov/Pubs/pdf/02154-Medicare-Hospice-Benefits.PDF . Accessed May 14, 2018.

Centers for Medicare & Medicaid Services (CMS). MLN Hospice Payment System: ICN: 006817. October 2017. Available at: http://www.cms.gov/MLNProducts/downloads/hospice_pay_sys_fs.pdf. Accessed May 14, 2018.

Cigna Government Services (CGS) Administrators, LLC. Local Coverage Determination (LCD). L34583: Hospice determining terminal status. [CMS Web site]. 10/01/2015. Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34538&ContrId=236&ver=3&ContrVer=2&CntrctrSelected=236*2&Cntrctr=236&DocType=Active%7cFuture&s=All&bc=AggAAAQAAAAAAA%3d%3d&. Accessed May 16, 2018.

Evidence of Coverage.

Federal Register. Vol. 70, No. 224: Rules and Regulations. Department of Health and Human Services. Centers for Medicare and Medicaid Services (CMS). 42 CFR, Part 418. Medicare Program; Hospice Care Amendments. [Federal Register Online Web site]. 11/22/05. Available at: http://edocket.access.gpo.gov/2005/pdf/05-23078.pdf. Accessed May 14, 2018.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)



0651 Hospice Service - Routine Home Care

0652 Hospice Service - Continuous Home Care

0655 Hospice Service - Inpatient Respite Care

0656 Hospice Service - General Inpatient Care Non-Respite

0657 Hospice Service - Physician Services

Coding and Billing Requirements






Policy History

MA02.001a:
06/20/2018Effective 6/20/2018, this policy has undergone a routine review, and no revisions have been made.
02/10/2017This version of the policy will become effective 02/10/2017.

The policy has been reviewed and reissued to communicate the Company’s continuing position on hospice and respite Care.

MA02.001:
01/06/2016This policy has been reviewed and reissued to communicate the Company’s continuing position on Hospice Care.
01/07/2015This policy has been reviewed and reissued to communicate the Company’s continuing position on Hospice Care.
01/01/2015This is a new policy.






Version Effective Date: 02/10/2017
Version Issued Date: 02/10/2017
Version Reissued Date: 06/20/2018