LCD L34547

Coverage Guidance

Title XVIII of the Social Security Act, §1861 (dd)(1) states the term "hospice care" means the services provided to a hospice patient.

Title XVIII of the Social Security Act, §1862 (a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Title XVIII of the Social Security Act, §1862 (a)(6) addresses items and services which constitute personal comfort items (except, in the case of hospice care, as is otherwise permitted under paragraph (1)(C)).

Title XVIII of the Social Security Act, §1862 (a)(9) addresses items and services where such expenses are for custodial care (except in the case of hospice care, as is otherwise permitted under paragraph (1)(C)).

Title XVIII of the Social Security Act, §1812 (a)(4) states in lieu of certain benefits, hospice care with respect to the individual during up to two periods of 90 days each and unlimited number of subsequent periods of 60 days each with respect to which the individual makes an election under subsection (d)(1).

Title XVIII of the Social Security Act, §1814 (a)(7)(A)(i) addresses certifying the patient for hospice.

42 CFR §418 Hospice Care

CMS Internet-Only Manual, Pub. 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 1, §10.1 Hospital Insurance (Part A) for Inpatient Hospital, Hospice, Home Health and Skilled Nursing Facility (SNF) Services - A Brief Description

CMS Internet-Only Manual, Pub. 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4, §60 Certification and Recertification by Physicians for Hospice Care

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 9, §10 Requirements - General, §20.1 Timing and Content of Certification, §20.2.1 Hospice Election, §20.2.1.1 Hospice Election Statement, §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, §40.1.4 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, §40.2.1 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 and §80 Hospice Pre-Election Evaluation and Counseling Services

Indications and Limitations of Coverage

Neurological conditions are associated with impairments, activity limitations, and disability. Their impact on any given individual depends on the individual’s overall health status. Health status includes environmental factors, such as the availability of palliative care services. The objective of this policy is to present a framework for identifying, documenting, and communicating the unique health care needs of individuals with neurological conditions and thus promote the overall goal of the right care for every person, every time.

Neurological conditions may support a prognosis of 6 months or less under many clinical scenarios. Medicare rules and regulations addressing hospice services require the documentation of sufficient clinical information and other documentation to support the certification of individuals as having a terminal illness with a life expectancy of 6 or fewer months, if the illness runs its normal course. The identification of specific structural/functional impairments, together with any relevant activity limitations, should serve as the basis for palliative interventions and care-planning.

Additionally, the care plan may be impacted by relevant secondary and/or comorbid conditions. Secondary conditions are directly related to a primary condition. In the case of neurological conditions, examples of secondary conditions could include dysphagia, pneumonia, and pressure ulcers. Comorbid conditions affecting beneficiaries with neurological conditions are, by definition, distinct from the primary condition itself, however, services aimed at the comorbid condition may indeed be related to the palliation and/or management of the terminal condition. An example of a comorbid condition would be chronic obstructive pulmonary disease (COPD).

The important roles of secondary and comorbid conditions are described below in order to facilitate their recognition and assist providers in documenting their impact. The identification and documentation of relevant secondary and comorbid conditions, together with the identification and description of associated structural/functional impairments, activity limitations, and environmental factors would help establish hospice eligibility and maintain a beneficiary-centered plan of care.

Secondary Conditions:

Neurological conditions may be complicated by secondary conditions. The significance of a given secondary condition is best described by defining the structural/functional impairments - together with any limitation in activity and restriction in participation - related to the secondary condition. The occurrence of secondary conditions in beneficiaries with neurological conditions results from the presence of impairments in such body functions as consciousness, attention, sequencing complex movements, ingestion (which includes chewing, manipulation of food in the mouth, and swallowing), muscle power, tone, and endurance. These impairments contribute to the increased incidence of secondary conditions such as dysphagia, pneumonia, and pressure ulcers observed in Medicare beneficiaries with neurological conditions. Secondary conditions themselves may be associated with a new set of structural/functional impairments that may or may not respond or be amenable to treatment.

Ultimately, in order to support a hospice plan of care, the combined effects of the primary neurological condition and any identified secondary condition(s) should be such that most beneficiaries with the identified impairments would have a prognosis of 6 months or less.

Comorbid Conditions:

The significance of a given comorbid condition is best described by defining the structural/functional impairments - together with any limitation in activity and restriction in participation - related to the comorbid condition. For example, a beneficiary with a primary neurological condition such as amyotrophic lateral sclerosis (ALS) and a comorbidity of COPD could have specific COPD-related structural and functional impairments of respiration (e.g., structural impairments of the bronchoalveolar tree resulting in increased respiratory rate, cough and impaired gas exchange) that contribute to the activity limitations and participation restrictions already present due to the respiratory muscle weakness often observed with ALS.

Such a combination could affect the palliative care plan by contributing to the individual’s dyspnea and impaired exercise tolerance. Palliative care aimed at relieving the dyspnea and improving the individual’s health status would be the goal.

Ultimately, in order to support a hospice plan of care, the combined effects of the primary neurologic condition and any identified comorbid condition(s) should be such that most beneficiaries with the identified impairments would have a prognosis of 6 months or less. The documentation of structural/functional impairments, together with the observed activity limitations, facilitate the selection of the most appropriate intervention strategies (palliative/hospice vs. long-term disease management) and provide objective criteria for determining the effects of such interventions. The documentation of these variables is thus essential in the determination of reasonable and necessary Medicare hospice services.

Summary of Evidence

N/A

Analysis of Evidence

N/A

Associated Information

Documentation Requirements

1. Documentation supporting medical necessity should be legible, maintained in the patient’s medical record, and must be made available to the A/B HHH MAC upon request.

2. Documentation certifying terminal status must contain enough information to confirm terminal status upon review. Documentation meeting the criteria listed under the Coverage Indications, Limitations and/or Medical Necessity section of this policy would contribute to this requirement.

3. If the patient does not meet the criteria outlined under Coverage Indications, Limitations and/or Medical Necessity section of this policy, yet is deemed appropriate for hospice care, sufficient documentation of the patient's condition that justifies terminal status, in the absence of meeting the above criteria, would be necessary.

4. Recertification for hospice care requires that the same standards be met as for the initial certification.

Bibliography

1. Espinoza S, Walston JD. Frailty in older adults: Insights and interventions. Cleve Clin J Med. 2005;72(12):1105-1112.