order to be eligible for coverage under the member’s hospice benefit, the
attending physician must certify that the individual’s medical prognosis is that
his/her life expectancy is six months or less if the terminal illness runs the
expected course. The attending physician must have examined the member within 14
calendar days of request for authorization.
member’s prognosis improves substantially and the member’s life expectancy
exceeds six months, coverage for hospice care will be re-evaluated and could
eligible for hospice care, a member must have a personal caregiver for support.
Hospice is not a substitute for personal care.
services are intended to provide palliative care. Admission into a hospice
program does not mean that care is being withdrawn, but does mean that care
designed to be curative or life-prolonging is no longer intended. Hospice
provides treatments necessary for comfort, to improve function, or to alleviate
following types of services are considered to be compatible with hospice care
(not an all-inclusive list):
therapy for the purposes of relieving pain, for example, of a bony metastasis
for pain, regardless of route
for nausea, regardless of route
procedures to decompress a viscus, if required for comfort
following types of services are considered to be attempts at cure or
prolongation of life, and are not compatible with hospice care (examples only,
not an all-inclusive list):
therapy other than focal treatment to relieve pain
procedures for provision of nutrition, including placement of feeding tubes of
services are an integral part of hospice care. These counseling services may be
provided both for the purpose of training the member’s family or other
caregivers to provide care, and for the purpose of helping the member and those
caring for the member to adjust to the member’s approaching death. Counseling
services for family members for up to six months after death are included.
hospice is paid on a per diem basis. This per diem payment covers all
outpatient services related to care for the terminal disease, including
medications, durable medical equipment, supplies, skilled nursing services, and
aide services. The exceptions are radiation therapy and services related to use
of a pain pump, which are paid separately.
hospice is available for patients who develop symptoms that cannot be controlled
in the home. This may include pain that requires frequent changes in therapy to
determine appropriate dosing, or intractable vomiting. Once the patient is
stabilized enough that symptoms can be controlled on an outpatient basis, the
patient should return home with hospice.
recognized revenue codes for hospice services. HCPCS codes will not be
Used In This BI:
Revenue codes 0651, 0652, 0655 and 0656