Print

Date Printed: June 28, 2017: 11:49 PM

Private Property of Blue Cross and Blue Shield of Florida.
This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

01-99500-03

Original Effective Date: 10/01/10

Reviewed: 12/06/12

Revised: 05/11/14

Subject: Hospice Care

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
Other References Updates  

NOTE: Coverage for hospice care is subject to the member’s benefit terms, limitations and maximums. Refer to contract language regarding hospice care.

DESCRIPTION:

Hospice care is a comprehensive set of services, identified and coordinated by an interdisciplinary group to provide for the physical, psychosocial, spiritual, and emotional needs of a terminally ill member and/or family members, as delineated in a specific patient plan of care.

Hospice care includes services rendered by a hospice agency in a member’s home (e.g., residential, assisted living, retirement), a skilled nursing facility, intermediate care facility, a hospital, or other inpatient setting (e.g., residential hospice facility).

Hospice services are considered to be services specifically for the management of a terminal illness. Per the Florida Statutes, one is considered to be terminally ill if his/her medical prognosis is limited to one (1) year or less.

Certification of a terminal illness for hospice shall be based on the clinical judgment of the member’s attending physician and hospice medical director regarding the normal course of the member’s illness. The member (or his authorized representative) must elect hospice care.

Hospice care is defined by the services and care provided, in addition to the setting in which the services are delivered. The following levels of hospice care (routine, continuous, inpatient) may be provided:

Routine home care Fewer than eight hours of nursing care; may include skilled observation and monitoring, skilled care to control pain and other symptoms. Other routine home care, but not limited to therapy (e.g., respiratory, physical, occupational, speech), medical social worker services, nutritional counseling, pastoral counseling, and bereavement counseling.

Continuous home care (CHC) The hospice must provide a minimum of eight hours of care during a 24-hour day, which begins and ends at midnight. CHC is provided during a period of crisis; a period of crisis is a period in which a patient requires continuous care which is primarily nursing care (registered nurse (RN) or licensed practical nurse (LPN)) to achieve palliation or management of acute medical symptoms. Homemaker or home health aide services may be provided to supplement the nursing care. The fact that a patient is in the active dying process does not in itself justify CHC, apart from any need to address critically distressing symptoms in the patient.

Inpatient care Short-term inpatient care provided in a hospice inpatient facility when pain control, acute or chronic symptoms cannot be managed in the home, or the member’s condition has worsened and become medically unstable. The fact that a member is in the active dying process does not in itself justify inpatient care, apart from any need to address critically distressing symptoms in the member.

Respite care Short-term inpatient care provided to the member in a hospice facility to relieve the primary caregiver (e.g., family member, other persons) caring for the member. NOTE: Coverage for respite care services is covered according to member’s contract benefits; refer to specific member contract language.

Discharge from Hospice Care

If the member is no longer considered terminally ill, the member may be discharged from hospice. Also, a hospice discharge may be appropriate if the patient: refuses hospice care services, is uncooperative with the hospice plan of care, moves out of the service area, or transfers from one hospice program to another hospice program. Prior to discharge, the hospice must obtain a written discharge order from the hospice medical director.

POSITION STATEMENT:

NOTE: Coverage for hospice care is subject to the member’s benefit terms, limitations and maximums. Refer to specific contract language regarding hospice care.

Prior authorization or certification/notification may be required for hospice care, refer to member’s benefit.

If coverage is available for hospice care, the following criteria for coverage apply.

Hospice care meets the definition of medical necessity when ALL of the following criteria are met:

The member is terminally ill and expected to live one (1) year or less (for determining terminal illness status, refer to OTHER section of this guideline); AND

NOTE: Written certification statement(s) must be retained by the hospice and maintained in the member’s medical record.

Levels of Hospice Care

Prior notification is required for any change in level of hospice care.

The following levels of hospice care meet the definition of medical necessity when ALL of the hospice care criteria are met:

Routine Home Care

Routine home care for hospice includes skilled and supportive care provided on an intermittent basis in the member’s home, long-term care facility, or assisted living facility.

This level of care requires fewer than eight hours of nursing care per day and is based on the member’s needs. Nursing care may include, but not limited to:

Other routine home care for hospice includes, but is not limited to:

Continuous Home Hospice Care (CHC)

CHC is provided during a crisis in which the member requires continuous care which is primarily nursing care (RN or LPN). CHC is provided in the home and includes a minimum of 8 hours of direct patient care during a 24 hour day, which begins and ends at midnight. CHC need not be continuous (e.g., 4 hours may be provided in the morning and 4 hours may be provided in the evening), an aggregate of 8 hours of nursing care (RN or LPN) is required. Homemaker or home health aide services may be provided to supplement the nursing care.

The following are examples (not all inclusive) of CHC performed in the home when ALL of the hospice care criteria are met:

Inpatient Hospice Care

Inpatient hospice care meets the definition of medical necessity when ALL of the hospice care criteria AND following criteria are met:

Respite Care

Coverage for respite care services is covered according to member’s contract benefits; refer to specific member contract language.

Hospice Care Services

Hospice care services related to the terminal illness or condition are considered integral to the hospice care and are not separately reimbursable. Hospice care services related to the terminal illness or condition may include the following (not all inclusive):

NOTE: Medical equipment is provided by the hospice for use in the member’s home while the member is under hospice care. Medical supplies include supplies that are part of the written plan of care.

Medical Conditions

The following are examples (not all inclusive) of medical conditions that may be considered for hospice care when ALL of the hospice care criteria are met:

Non-Covered Services

The following hospice care services do not meet the definition of medical necessity (the following may not be all inclusive):

Discharge from Hospice Care

NOTE: Hospice providers must obtain a written discharge order from the hospice medical director prior to discharge of a member from hospice care.

A member may be discharged from hospice care for ANY of the following:

BILLING/CODING INFORMATION:

Coding requirements are based on national coding and billing guidelines, additional details may be found in the manual for physicians and providers.

REIMBURSEMENT INFORMATION:

Refer to member’s benefit plan limitations and maximums for hospice care.

Reimbursement for levels of hospice care (routine home care, continuous home care (CHC), or inpatient care) is based on medical necessity, subject to medical review.

LOINC Codes:

The following information may be required documentation to support medical necessity: physician history and physical, physician progress notes, plan of treatment, laboratory studies, and reason for hospice care.

Documentation Table

LOINC Codes

LOINC
Time Frame
Modifier Code

LOINC Time Frame Modifier Codes Narrative

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Attending physician progress note

18741-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Plan of treatment

18776-5

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

PROGRAM EXCEPTIONS:

Blue Card Host: Refer to member’s specific contract language regarding hospice care.

Federal Employee Program (FEP): Follow FEP guidelines.

Medicare Advantage products: No National Coverage Determination (NCD) and/or Local Coverage Determination (LCD) were found at the time of the last guideline reviewed date.

State Account Organization (SAO): Follow SAO guidelines.

DEFINITIONS:

Bereavement counseling: counseling services provided to the individual’s family after the individual’s death.

BMI (body mass index): a measure of body fat based on height and weight.

Cachexia: general ill health and malnutrition.

Custodial care: those services provided to a member primarily to assist in the activities of daily living or respite care or services provided for the sole purpose of allowing a family member or caregiver to return to work.

Hospice care: a comprehensive set of services, identified and coordinated by an interdisciplinary group to provide for the physical, psychosocial, spiritual, and emotional needs of a terminally ill patient and/ or family members, as delineated in a specified patient plan of care.

Hospice: a public agency or private organization or subdivision of either of these that is primarily engaged in providing hospice care.

Intractable: resistant to cure, relief, or control.

Palliative care: patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering.

Period of crisis: a period in which a patient requires continuous care, which is primarily nursing care to achieve palliation or management of acute medical symptoms.

Plan of care: a written assessment by the hospice of each member’s and family’s needs and preferences, and the services to be provided by the hospice to meet those needs.

Respite care (as related to this guideline): short-term inpatient care provided to the member in a hospice facility for respite to relieve the primary caregiver (e.g., family member, other persons) caring for the member.

Skilled services (as related to this guideline): services provided in accordance to physician orders that require the skills of professional personnel such as registered nurse or licensed practical nurse.

Terminally ill: member’s medical prognosis is limited to one (1) year or less.

RELATED GUIDELINES:

OTHER:

The member should be referred to case management, prior to initiation of hospice care. A case management plan of care should be developed with input from the attending physician, hospice medical director, hospice, and caregiver.

Determining Terminal Illness Status

The following may be documented in the member’s medical record as indication of decline in clinical status (not all inclusive):

Clinical Status of Terminal Illness

Symptoms of Terminal Illness

Signs of Terminal Illness

Functional Status Tools

Palliative Performance Scale (PPS)

Karnofsky Performance Scale (KPS)

 

Functional Assessment Staging (FAST)

REFERENCES:

  1. Abresch RT, Carter GT, Han JJ. New clinical end points in rehabilitation medicine: tools for measuring quality of life. American Journal of Hospice Palliative Care 2009; 26(6): 483-492.
  2. Anderson F, Downing GM, Hill J. et al. Palliative performance scale (PPS): a new tool. Journal of Palliative Care 1996; 12(1): 5-11.
  3. Brasel KJ. Quality-of-life assessment in palliative care. American Journal of Hospice Palliative Care 2007; 24(3): 231-235.
  4. Casarett DJ, Fishman JM, Lu Hl et al. The terrible choice: re-evaluating hospice eligibility criteria for cancer. Journal of Clinical Oncology 2009; 27(6): 953-959.
  5. Code of Federal Regulations (electronic) Title 42—Public Health, Part 418 Hospice Care, 2010.
  6. Crooks V, Waller S, Smith T et al. The use of the Karnofsky Performance Scale in determining outcomes and risk in geriatric outpatients. The Journals of Gerontology 1991; 46(4): M139-M144.
  7. Fowler K, Poehling K, Billheimer D et al. Hospice referral practices for children with cancer: a survey of pediatric oncologists. Journal of Clinical Oncology 2006; 24(7): 1099-1104.
  8. Harold J, Rickerson E, Carroll JT et al. Is the palliative performance scale a useful predictor of mortality in a heterogeneous hospice population? Journal of Palliative Medicine 2005; 8(3): 503-509.
  9. Lau F, Downing M, Lesperance M et al. Using the Palliative Scale to provide meaningful survival estimates. Journal of Pain and Symptom Management 2009; 38(1): 134-144.
  10. Medicare Benefit Policy Manual Chapter 9 – Coverage of Hospice Services Under Hospital Insurance, 06/01/12.
  11. Reisberg B. Functional assessment staging (FAST). Psychopharmacology Bulletin 1988; 24(4): 653-659.
  12. Ross DR, Alexander CS. Management of common symptoms in terminally III patients: Part I fatigue, anorexia, cachexia, nausea and vomiting. American Family Physician 2001; 64(5): 807-815.
  13. Ross DR, Alexander CS. Management of common symptoms in terminally III patients: Part II constipation, delirium and dyspnea. American Family Physician 2001; 64(6): 1019-1027.
  14. Salz T, Brewer NT. Offering chemotherapy and hospice jointly: one solution to hospice underuse. Medical Decision Making 2009; 29: 521-531.
  15. Schag CC, Heinrich RL, Ganz PA. Karnofsky performance status revisited: reliability, validity, and guidelines. Journal of Clinical Oncology 1984; 2(3): 187-193.
  16. Sclan SG, Reisberg B. Functional assessment staging (FAST) in Alzheimer’s disease: reliability, validity, and ordinality. International Psychogeriatric 1992; 4 Suppl 1:55-69.
  17. Florida Statutes Chapter 400 Nursing Homes and Related Health Care Facilities Part IV-Hospices.
  18. Weng LC, Huang HL, Wilkie DJ et al. Predicting survival with the palliative performance scale in a minority-serving hospice and palliative care program. Journal of Pain and Symptom Management 2009; 37: 642-648

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 12/06/12.

GUIDELINE UPDATE INFORMATION:

10/01/10

New Medical Coverage Guideline.

11/15/10

Deleted criteria regarding curative treatment or therapy.

10/01/11

Revision; formatting changes.

10/15/11

Annual review; maintain position statements. Updated references.

12/15/11

Added functional assessment tools (Palliative Performance Scale (PPS), Karnofsky Performance Scale (KPS) and Functional Assessment Staging (FAST). Updated references.

01/15/13

Annual review; no change in position statement and updated references.

05/11/14

Revision: Program Exceptions section updated.

Date Printed: June 28, 2017: 11:49 PM