Billing and Coding: Hospice: Determining Terminal Status

This article contains coding and other guidelines that complement the Local
Coverage Determination (LCD) for Hospice - Determining Terminal Status.

**National Coverage Provisions:**

_With passage of the Affordable Care Act in March 2010, Congress required
hospice physicians or hospice nurse practitioners to have a face-to-face
encounter with Medicare hospice patients prior to the 180th-day
recertification and every recertification thereafter, and to attest that the
encounter occurred. CMS proposed and implemented policies related to this new
requirement in the Home Health Prospective Payment System Rate Update for CY
2011; Changes in Certification Requirements for Home Health Agencies and
Hospices Final Rule (75 FR 70372). This new face-to-face encounter requirement
became effective on January 1, 2011._

_Hospice certifications and recertifications must include a brief narrative
explanation of the clinical findings that supports a life expectancy of 6
months or less, either as part of the form or as an addendum. Physicians must
briefly synthesize the clinical information supporting the terminal diagnosis,
and attest that they composed the narrative after reviewing the clinical
information, and where applicable, examining the patient. The narrative must
reflect the patient 's individual clinical circumstances. Narratives
associated with the third and later benefit period must also include an
explanation of why the clinical findings of the face-to-face encounter support
a life expectancy of 6 months or less. (_CMS Pub 100-02 _. Medicare Benefit
Policy Manual,_ Chapter 9, Section 20.1 _)_

_For recertifications on or after January 1, 2011, a hospice physician or
hospice nurse practitioner must have a face-to-face encounter with each
hospice patient prior to the beginning of the patient 's third benefit period,
and prior to each subsequent benefit period. (_CMS Pub 100-02 _. Medicare
Benefit Policy Manual,_ Chapter 9, Section 20.1 _)_

_A hospice physician or hospice nurse practitioner must have a face-to-face
encounter with patients prior to the third benefit period recertification and
each subsequent recertification. This encounter can occur up to 30 calendar
days prior to recertification, and the hospice physician or nurse practitioner
must attest that the visit occurred. The certification or recertification must
include the benefit period dates to which it applies, and be signed and dated
by the certifying or recertifying physician. Initial certifications may be
prepared no more than 15 calendar days prior to the effective date of
election. Recertifications may be prepared no more than 15 calendar days prior
to the start of the subsequent benefit period. (_ CMS Pub 100-02 _, Medicare
Benefit Policy Manual,_ Chapter 9, Section 20.1 _)_

_Hospice nurse practitioners may conduct face-to-face encounters as described
in 20.1(5) as part of the certification process, but are still prohibited by
statute from certifying the terminal illness. (_CMS Pub 100-02 _. Medicare
Benefit Policy Manual,_ Chapter 9, Section 20.1)

**Coding Information:**

Procedure codes may be subject to National Correct Coding Initiative (NCCI)
edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to
billing Medicare.

For services requiring a referring/ordering physician, the name and NPI of the
referring/ordering physician must be reported on the claim.

A claim submitted without a valid ICD-10-CM diagnosis code will be returned to
the provider as an incomplete claim under Section 1833(e) of the Social
Security Act.

The diagnosis code(s) must best describe the patient's condition for which the
service was performed. For diagnostic tests, report the result of the test if
known; otherwise the symptoms prompting the performance of the test should be
reported. **  
  
 **  
  
 **For claims submitted to the fiscal intermediary or Part A MAC:**  
  
The patient's principal diagnosis, i.e., the terminal illness, should be
reported in Form Locator (FL) 67 of the UB-04. Additional or secondary
diagnoses, i.e., comorbidities, may be reported in FLs 67A - 67Q.  
  
**Reasons for Denial**  
  
Medical review of records of hospice patients that do not document that
patients meet the guidelines set forth in the LCD may result in denial of
coverage unless other clinical circumstances reasonably predictive of a life
expectancy of six months or less are provided.  
  
The condition of some patients receiving hospice care may stabilize or improve
during or due to that care, with the expectation that the stabilization or
improvement will not be brief and temporary. In such circumstances, if the
patient's condition changes such that he or she no longer has a prognosis of
life expectancy of six months or less, and that improvement can be expected to
continue outside the hospice setting, then that patient should be discharged
from hospice.

**Documentation Guidelines:**  

Documentation certifying terminal status must contain enough information to
support terminal status upon review. Documentation of the applicable criteria
listed under the "Indications" section of the LCD would meet this requirement.
If other clinical indicators of decline not listed in tthe LCD form the basis
for certifying terminal status, they should be documented as well.
Recertification for hospice care requires the same clinical standards be met
as for initial certification, but they need not be reiterated. They may be
incorporated by specific reference as part (or all) of the indication for
recertification.

Documentation should "paint a picture" for the reviewer to clearly see why the
patient is appropriate for hospice care and the level of care provided, i.e.,
routine home, continuous home, inpatient respite, or general inpatient. The
records should include observations and data, not merely conclusions. However,
documentation should comport with normal clinical documentation practices.
Unless elements in the record require explanation, such as a non-morbid
diagnosis or indicators of likely greater than six month survival, as stated
below, no extra or additional record entries should be needed to show hospice
benefit eligibility.

The amount and detail of documentation will differ in different situations. A
patient with metastatic small cell CA may be demonstrated to be hospice
eligible with less documentation than one with chronic lung disease. Patients
with chronic lung disease, long term survival in hospice, or apparent
stability can still be eligible for hospice benefits, but sufficient
justification for a less than six-month prognosis should appear in the record.

If the documentation includes any findings inconsistent with or tending to
disprove a less than six-month prognosis, they should be answered or refuted
by other entries, or specifically addressed and explained. Most facts and
observations tending to suggest a greater than six month prognosis are
predictable and apparent, such as a prolonged stay in hospice or a low
immediate mortality diagnosis, as stated above. But specific entries can also
call for an answer, such as an opinion by one team member or recovery of ADLs
when they were part of the basis for the initial declaration of eligibility.
Also the lack of certain elements such as a tissue diagnosis for cancer will
not negate eligibility, but does necessitate other supportive documentation.

Documentation submitted may include information from periods of time outside
the billing period currently under review. Include supporting events such as a
change in the level of activities of daily living, recent hospitalizations,
and the known date of death (if you are billing for a period of time prior to
the billing period in which death occurred).

Submitted documentation should always include the admission assessment, as
well as any evaluations and Interdisciplinary Group (IDG) discussions used for
recertification. Records that show the progression of the patient's illness
are very helpful.

Documentation should support the level of care being provided to the patient
during the time period under review, i.e. routine or continuous home or
inpatient, respite or general. The reviewer should be able to easily identify
the dates and times of changes in levels of care and the reason for the
change.