Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Hospice Care

Policy #:02.02.01g

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


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. 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.

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 Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

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

HOSPICE CARE

Hospice care is covered and eligible for reimbursement consideration by the Company when all of the following criteria are met:
  • The hospice provider must be all of the following:
    • Certified by Medicare to provide hospice services
    • Accredited as a hospice by an independent accrediting organization recognized by the Company
    • Appropriately licensed in the state where it is located
  • The hospice care program delivers hospice care in accordance with a treatment plan, which may include one or more of the following services:
    • Pain and symptom relief
    • Physical care
    • Counseling
    • Other services that will help the individual cope with a terminal illness
  • The individual's attending physician (if the individual has one) and the Hospice Medical Director (or physician member of the Interdisciplinary Group [IDG]) certifies for the initial period that the covered individual has a terminal illness with an anticipated life expectancy of six months or less.
    • For subsequent periods the hospice physician recertifies the individual.
  • Hospice care is performed in an eligible place of service such as, but not limited to, any one of the following:
    • A home (including anywhere an individual resides on a permanent basis)
    • A hospice facility
    • A skilled nursing facility (SNF)
    • An acute care hospital that is only covered and eligible for reimbursement consideration by the Company when all of the following criteria are met:
      • An individual is experiencing the end stage of a terminal illness
      • The individual is accepted by a hospice care program
      • The individual's care becomes too complex to be managed in the home setting and requires greater than eight hours per day skilled nursing care that cannot be provided in another setting. Examples include, but are not limited to:
        • Uncontrollable pain
        • Intractable nausea/vomiting
        • Restlessness/agitation
        • Intractable diarrhea
        • Respiratory distress
  • Documentation of ongoing skilled needs that meet the above requirements

Hospice benefits will not be provided for:
  • Services and supplies that are free of charge (e.g., prayer services performed by the clergy)
  • Research studies directed to life-extension methods of treatment
  • Services or expenses incurred in regard to the individual's personal, legal, and financial affairs (such as preparation and execution of a will or other dispositions of personal and real property)
  • Care performed by family members, relatives, and friends
  • Private duty nursing care
  • Treatment to cure the individual's underlying terminal illness

HOSPICE RESPITE CARE
For individuals receiving eligible hospices services primarily in the home, when short-term, inpatient, respite care is provided in a Medicare certified skilled nursing facility (SNF), reimbursement is included in the global payment to the hospice care provider. Limitations on frequency and duration of the stay vary by product and group.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the professional provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Guidelines

BENEFIT APPLICATION

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

Dental and vision benefits remain unaffected for members who have hospice benefits.

Benefits for home hospice, inpatient hospice, and respite care vary per benefit contract and per Company product. Individual benefits must be verified, as not all groups have the same level of coverage for hospice and respite care.

All services related to the individual's terminal illness are facilitated by the hospice provider (this includes nursing, physical therapy, social, and home health aide services, and medical supplies, drugs, and biologicals). Reimbursement for in-network hospice care is based on the hospice care provider's contract with the Company.

Any services and/or procedures performed by someone other than the hospice care provider and unrelated to the terminal illness would be processed within the rules, guidelines, and limitations of the Company's current policies.

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). 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). 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). 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.

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.

Company Benefit Contracts.

Connor S, Pyenson B, Fitch K, et al. Comparing hospice and nonhospice patient survival among patients who die within a three-year window. J Pain Symptom Manage.2007;33(3):238-46.

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.

National Consensus Project for Quality Palliative Care. Clinical Practice Guidelines for Quality Palliative Care. 3rd ed. Pittsburgh, PA: The National Consensus Project for Quality Palliative Care; 2013. Available at: https://www.hpna.org/multimedia/NCP_Clinical_Practice_Guidelines_3rd_Edition.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)

THE FOLLOWING REVENUE CODES MUST BE REPORTED BY COMPANY-CONTRACTED HOSPICE CARE PROVIDERS:


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


Cross References


Policy History

Revisions from 02.02.01g:
06/20/2018Effective 6/20/2018, this policy has undergone a routine review, and no revisions have been made.


Effective 10/05/2017 this policy has been updated to the new policy template format.

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

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2017 Independence Blue Cross.
Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.