(Medicare Benefit Policy Manual)

Medicare Benefit Policy Manual  Chapter 9 - Coverage of Hospice Services Under  Hospital Insurance   Table of Contents  (Rev. 12385, Issued:  11-30-23)  Transmittals for Chapter 9  10 - Requirements -  General  20 - Certification and Election Requirements  20.1 -  Timing and Content of Certification  20.2 -  Election, Revocation, and Discharge  20.2.1 -  Hospice Election  20.2.1.1  Hospice Election  Statement  20.2.1.2 Hospice Election Statement Addendum  20.2.1.3 Hospice Notice of Election  20.2.2 -  Hospice Revocation  20.2.3 -  Hospice Discharge 20.2.4- Hospice Notice of Termination or Revocation 20.3 -  Election by Skilled Nursing Facility (SNF) and Nursing Facilities (NFs) Residents and Dually Eligible Beneficiaries  20.4 -  Election by Managed Care Enrollees  30 - Coinsurance  30.1 -  Drugs and Biologicals Coinsurance  30.2 -  Respite Care Coinsurance  40 - Benefit Coverage  40.1 -  Covered Services  40.1.1 -  Nursing Care  40.1.2 -  Medical Social Services  40.1.3 -  Physicians' Services  40.1.3.1 -  Attending Physician Services  40.1.3.2 -  Nurse Practitioners as Attending Physicians  40.1.3.3 -  Physician Assistants as Attending Physicians  40.1.4 -  Counseling Services  40.1.5 -  Short -Term Inpatient Care  40.1.6 -  Medical Appliances and Supplies  40.1.7 -  Hospice Aide and Homemaker Services  40.1.8 -  Physical Therapy, Occupational Therapy, and Speech -Language Pathology 40.1.9 -  Other Items and Services  40.2 -  Special Services  40.2.1 -  Continuous Home Care (CHC)  40.2.2 -  Respite Care  40.2.3 -  Bereavement Counseling  40.2.4 -  Special Modalities  40.3 -  Contracting With Physicians  40.4 -  Core Services  40.4.1 -  Contracting for Core Services  40.4.1.1 -  Contracting for Highly Specialized Nursing Services  40.4.2 -  Waiver for Certain Core Staffing Requirements  40.4.2.1 -  Waiver for Certain Core Nursing Services  40.5 -  Non -Core Services  50 - Limitation on Liability for Certain Hospice Coverage Denials  60 - Provision of Hospice Services to Medicare/Veterans Eligible Beneficiaries  70  Hospice Contracts with An Entity for Services not Considered Hospice Services  70.1 -  Instructions for the Contractual Arrangement  80  Hospice Pre- Election Evaluation and Counseling Services  80.1  Documentation  80.2 -  Payment  90 - Caps and Limitations on Hospice Payments  90.1 -  Limitation on Payments for Inpatient Care  90.2 -  Aggregate Cap on Overall Reimbursement to Medicare- certified Hospices  90.2.1 -  New Hospices  90.2.2 -  Counting Beneficiaries for Calculation  90.2.3 -  Changing Aggregate Cap Calculation Methods  90.2.4 -  Other Issues  90.2.5 -  Updates to the Cap Amount  90.3 -  Administrative Appeals10 - Requirements - General  (Rev. 246, Issued: 09- 14-18, Effective: 12 -17- 18, Implementation: 12- 17-18)  Hospice care is a benefit under the hospital insurance program.  To be eligible to elect hospice care under Medicare, an individual must be entitled to Part A of Medicare and be certified as being terminally ill.  An individual is considered to be terminally ill if the medical prognosis is that the individuals life expectancy is 6 months or less if the illness runs its normal course.  Only care provided by (or under arrangements made by) a Medicare certified hospice is covered under the Medicare hospice benefit.   The hospice admits a patient only on the recommendation of the medical director in consultation with, or with input from, the patient's attending physician (if any).   In reaching a decision to certify that the patient is terminally ill, the hospice medical director must consider at least the following information:  (1) Diagnosis of the terminal condition of the patient. (2) Other health conditions, whether related or unrelated to the terminal condition.  (3) Current clinically relevant information supporting all diagnoses.  Section 1814(a)(7)  of the Social Security Act (the Act) specifies that certification of terminal illness for hospice benefits shall be based on the clinical judgment of the hospice medical director or physician member of the interdisciplinary group (IDG) and the individual s attending physician, if he/she has one, regarding the normal course of the individuals illness.  No one other than a medical doctor or doctor of osteopathy can certify or re -certify a terminal illness.  Predicting of life expectancy is not always exact.   The fact that a beneficiary lives longer than expected in itself is not cause to terminate benefits. Attending physician is further defined in section 20.1 and 40.1.3.1.  An individual (or his authorized representative) must elect hospice care to receive it.  The first election is for a 90 -day period.  An individual may elect to receive Medicare coverage for two 90- day periods, and an unlimited number of 60- day periods.  If the individual (or authorized representative) elects to receive hospice care, he or she must file an election statement with a particular hospice.  Hospices obtain election statements from the individual and file a Notice of Election with the Medicare contractor, which transmits them to the Common Working File (CWF) in electronic format.  Once the initial election is processed, CWF maintains the beneficiary in hospice status unt il a final claim indicates a discharge (alive or due to death) or until an election termination is received.  For the duration of the election of hospice care, an individual must waive all rights to Medicare payments for the following services:    Hospice care provided by a hospice other than the hospice designated by the individual (unless provided under arrangements made by the designated hospice); and    Any Medicare services that are related to the treatment of the terminal condition for which hospice care was elected or a related condition, or services that are equivalent to hospice care, except for services provided by:   1.  The designated hospice (either directly or under arrangement);   2.  Another hospice under arrangements made by the designated hospice; or   3.  The individuals attending physician, who may be a nurse practitioner (NP) or a physician assistant (PA), if that physician, NP, or PA is not an employee of the designated hospice or receiving compensation from the hospice for those services.   Medicare services for a condition completely unrelated to the terminal condition for which hospice was elected remain available to the patient if he or she is eligible for such care.   20 - Certification and Election Requirements  (Rev. 1, 10- 01-03) A3-3141, HO -204  20.1 - Timing and Content of Certification  (Rev. 246, Issued: 09- 14-18, Effective: 12 -17- 18, Implementation: 12- 17-18)  For the first 90 -day period of hospice coverage, the hospice must obtain, no later than 2 calendar days after hospice care is initiated, (that is, by the end of the third day), oral or written certification of the terminal illness by the medical director of the hospice or the physician member of the hospice IDG, and the individuals attending physician if the individual has an at tending physician.  No one other than a medical doctor or doctor of osteopathy can certify or re -certify an individual as terminally ill, meaning that the individual has a medical prognosis that his or her life expectancy is 6 months or less if the illness runs its normal course.  Nurse practitioners and physician assistants cannot certify or re -certify an individual as terminally ill. In the event that a beneficiarys attending physician is a nurse practitioner or a physician assistant, the hospice medical director or the physician member of the hospice IDG certifies the individual as terminally ill.   The attending physician is a doctor of medicine or osteopathy who is legally authorized to practice medicine or surgery by the state in which he or she performs that function, a nurse practitioner, or physician assistant, and is identified by the individua l, at the time he or she elects to receive hospice care, as having the most significant role in the determination and delivery of the individuals medical care.  A nurse practitioner is defined as a registered nurse who performs such services as legally au thorized to perform (in the state in which the services are performed) in accordance with State law (or State regulatory mechanism provided by State law) and who meets training, education, and experience requirements described in 42 CFR 410.75.  A PA is defined as a professional who has graduated from an accredited physician assistant educational program who performs such services as he or she is legally authorized to perform (in the State in which the services are performed) in accordance with  State law (or State regulatory mechanism provided by State law) and who meets the training, education, and experience requirements as the Secretary may prescribe.  The PA qualifications for eligibility for furnishing services under the Medicare program ca n be found in the regulations at 42 CFR 410.74 (c).   Note that a rural health clinic or federally qualified healthcare clinic (FQHC) physician can be the patients attending physician but may only bill for services as a physician under regular Part B rules.  These services would not be considered rural health clinic or FQHC services or claims (e.g., the physicians do not bill under the rural health clinic provider number but they bill under their own provider number) .  Initial certifications may be completed up to 15 days before hospice care is elected. Payment normally begins with the effective date of election, which is the same as the admission date.  If the physician forgets to date the certification, a notarized sta tement or some other acceptable documentation can be obtained to verify when the certification was obtained.   For the subsequent periods, recertifications may be completed up to 15 days before the next benefit period begins.  For subsequent periods, the hospice must obtain, no later than 2 calendar days after the first day of each period, a written certification s tatement from the medical director of the hospice or the physician member of the hospices IDG.  If the hospice cannot obtain written certification within 2 calendar days, it must obtain oral certification within 2 calendar days.  When making an oral certi fication, the certifying physician(s) should state that the patient is terminally ill, with a prognosis of 6 months or less.  Because oral certifications are an interim step sometimes needed while all the necessary documentation for the written certification is gathered, it is not necessary for the physician to sign the oral certification.  Hospice staff must make an appropriate entry in the patient's medical record as soon as they receive an oral certification.  The hospice must obtain written certification of terminal illness for each benefit period, even if a single election continues in effect.  A written certification must be on file in the hospice patients record prior to submission of a claim to the Medicare contractor.  Clinical information and other documentation that support the medical prognosis must accompany the certification and must be  filed in the medical record with the written certification.  Initially, the clinical information may be provided verbally, and must be documented in the medical record and included as part of the hospice's eligibility assessment.   A complete written certification must include:  1.  the statement that the individuals medical prognosis is that their life expectancy is 6 months or less if the terminal illness runs its normal course;   2.  specific clinical findings and other documentation supporting a life expectancy of 6 months or less;   3.  the signature(s) of the physician(s), the date signed, and the benefit period dates that the certification or recertification covers (for more on signature requirements, see Pub. 100- 08, Medicare Program Integrity Manual, chapter 3, section 3.3.2.4).  4.  as of October 1, 2009, the physicians brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less as  part of the certification and recertification forms, or as an addendum to the certification and recertification forms;    If the narrative is part of the certification or recertification form, then the narrative must be located immediately above the physicians signature.    If the narrative exists as an addendum to the certification or recertification form, in addition to the physicians signature on the certification or recertification form, the physician must also sign immediately following the narrative in the addendum.   The narrative shall include a statement directly above the physician signature attesting that by signing, the physician confirms that he/she composed the narrative based on his/her review of the patients medical record or, if applicable, his or her examination of the patient.  The physician may dictate the narrative.