LCD L34559

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).

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).

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.

Title XVIII of the Social Security Act, §1813 (a)(4)(A)(i) addresses drugs and biologicals provided in a hospice program.

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 4, §60 Certification and Recertification by Physicians for Hospice Care

CMS Internet-Only Manual, Pub. 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Ch 5, §60 Hospice Defined, §60.1 Subdivision of Organizations as Hospices and §60.2 Arrangements by Hospices

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, §40 Benefit Coverage and §80 Hospice Pre-Election Evaluation and Counseling Services

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 11, §40 Other Services

Federal Register, Volume 70, No. 224, dated Tuesday, November 22, 2005, page 70537

Indications and Limitations of Coverage

End stage renal disease (ESRD) may support a prognosis of 6 months or less under many clinical scenarios. The identification of specific structural/functional impairments, together with any relevant activity limitations, should serve as the basis for palliative interventions and care planning. The structural and functional impairments associated with a primary diagnosis of ESRD are often complicated by comorbid and/or secondary conditions. Comorbid conditions affecting beneficiaries with ESRD are by definition distinct from the ESRD itself - examples include vascular disease manifested as coronary heart disease (CHD), peripheral vascular disease (PVD), and vascular dementia. Secondary conditions, on the other hand, are directly related to a primary condition. In the case of ESRD, examples include secondary hyperparathyroidism, calciphylaxis, nephrogenic systemic fibrosis, electrolyte abnormalities and anorexia. The important roles of comorbid and secondary conditions are described below in order to facilitate their recognition and assist providers in documenting their impact.

Medicare rules and regulations 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. For beneficiaries with ESRD the identification of relevant comorbid and secondary 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:

ESRD 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 - related to the secondary condition. The occurrence of secondary conditions in beneficiaries with ESRD is facilitated by the presence of impairments in such body functions as urinary excretory function, water, mineral and electrolyte function, and endocrine gland functions. Such functional impairments contribute to the increased incidence of secondary conditions such as hyperkalemia, fluid overload, and secondary hyperparathyroidism observed in Medicare beneficiaries with ESRD. Secondary conditions themselves may be associated with a new set of structural/functional impairments that may or may not respond/be amenable to treatment. Ultimately, the combined effects of the ESRD and any secondary condition should be such that most beneficiaries with ESRD and similar 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 - related to the comorbid condition. For example, a beneficiary with ESRD and clinically significant CHD would have specific impairments of cardiovascular structure/function (e.g., narrowing of coronary arteries, dyspnea, orthopnea, chest pain) which may or may not respond/be amenable to treatment. The identified impairments in cardiovascular structure/function may be associated with activity limitations (e.g., mobility, self-care). Ultimately, the combined effects of the ESRD and any comorbid condition should be such that most beneficiaries with ESRD and similar impairments would have a prognosis of 6 months or less.

The documentation of structural/functional impairments and activity limitations facilitates the selection of intervention strategies (palliative vs. long-term disease management/curative) and provides 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

Documentation must be legible, relevant and sufficient to justify the services billed. This documentation must be made available to the A/B HHH MAC upon request.

The documentation in the hospice patient’s medical record should contain sufficient “clinical” information to support the certification or the individual as having a terminal illness with a life expectancy of 6 or fewer months, if the illness runs its normal course.

For beneficiaries with ESRD, the identification of relevant comorbid and secondary 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.

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

Bibliography

1. Murray AM, Arko C, Chen SC, Gilbertson DT, Moss AH. Use of hospice in the United States dialysis population. Clin J Am Soc Nephrol. 2006;1(6):1248-1255.

2. Daram SR, Cortese CM, Bastani B. Nephrogenic fibrosing dermopathy/nephrogenic systemic fibrosis: Report of a new case with literature review. Am J Kidney Dis. 2005;46(4):754-759.

3. Himmelfarb J. Core curriculum in nephrology: Hemodialysis complications. Am J Kidney Dis. 2005;45(6):1122-1131.

4. Moss AH, Holley JL, Davison SN, et al. Core curriculum in nephrology: Palliative care. Am J Kidney Dis. 2004;43(1):172-185.

5. Wiggins J. Core curriculum in nephrology: Geriatrics. Am J Kidney Dis. 2005;46(1):147-158.