Hospice- Criteria and Services Flashcards
What predicts someone’s likelihood to enroll in Medicare Hospice?
1) Being a WOMAN
2) Being MARRIED
3) Having CANCER
4) Having Managed Care Medicare (Having FFS Medicare associated with lower hospice use)
5) Age > 75, being OLDER
What is covered under the following in Medicare?
1) PART A
2) PART B
3) PART C
4) PART D
1) PART A: HOSPICE, hospitals, skilled SNF, home health (annual deductible)
2) PART B: Medical providers, imaging, labs, ambulance, outpatient treatment, DME (annual deductible + FFS 80/20)
3) PART C: Medicare Advantage
4) PART D: Drugs, need to pay monthly premium
What ECOG qualifies someone for hospice?
ECOG 2 or HIGHER
KPS/PPS 70 or lower
What hospice team members are REQUIRED as defined by Medicare Hospice Benefit/COP?
1) Physician services
2) Nursing services
3) SW services
4) Bereavement counseling
5) Dietary counseling
6) Spiritual counseling
Requirement for Continuous Care?
1) Minimum of 8 hours of which at least 50% care by RN/LVN/LPN and the remainder is by a hospice aide (CNA)
2) MUST have skilled need (needing symptom control or skilled nursing care)- CG breakdown is NOT a good reason (unless family member WAS doing skilled care)
How frequently may a family access Respite Care? For how long?
Theoretically- more than once during a benefit period
Respite period CANNOT exceed 5 days each time
What are the indications for GIP?
1) Acute symptom management that cannot be done in another setting
2) NO specified number of days but need DAILY evaluation/documentation supporting ongoing need
3) Plans for discharge to lower level of care must be established EARLY on
What are the ONLY 3 reasons a patient can be discharged BY the hospice?
1) Moves from area or transfers to new hospice (can be done once per BP)
2) Hospice determines patient is no longer terminally ill
3) Hospice determines that delivery of care/ability to operate is seriously impaired by actions of the patient/persons in home and EXTENSIVE EFFORTS to resolve this have been tried
How can a family appeal a hospice discharge?
Can appeal to the designated QIO
- hospice care continues while appeal is pending
- QIO must give timely determination
- Hospice may NOT bill for care unless it has a valid certification of terminal illness
What 7 metrics are tracked by NQF for hospice agencies? (AKA Hospice Item Set or HQRP)
1) TX preferences
2) Beliefs/values addressed
3) Pain screening
4) Pain assessment
5) Dsypnea screening
6) Dyspnea assessment
7) Patients on opioids WHO ALSO HAVE BOWEL REGIMEN
Hospice use by different ethnicities
49.2% of white beneficiaries
40.2% of Hispanic
37.3% of African American
32% of Asian American
How early can Narratives be completed prior to start of BP? COTI? F2F visit?
Narratives/Certifications for ALL BPs
- No earlier than 15 days before BP start
F2F Visit
No earlier than 30 days prior to start of 3rd BP or subsequent BP
Must be done BEFORE or on same day as Narrative/Certification
Who can do a F2F visit?
MD or NP (NP must be employed by hospice)
CANNOT BE A PA
SIA can be billed for which two types of visits? Maximum billable hours per day?
1) RN visits in last 7 days of life
2) SW visits in last 7 days of life
Total of up to 4 hours per day
What are the 3 situations where a hospice agency is required to issue an ABN (advanced beneficiary notice)?
1) When the level of hospice care is determined not to be reasonable or medically necessary (GIP etc)
2) When items or services billed separately from the hospice benefit are not reasonable or necessary
3) When the beneficiary is determined not to be “terminally ill.”
What is the next step after discharging patient for cause?
Notify the Medicare Administrative Contractor (MAC) and state survey agency.
Billing code for an AOR not employed by hospice?
Medicare B- GV modifier
Billing code for specialist in community for problem NOT related to terminal illness?
Medicare B- GW modifier
Billing code for specialist in community for problem NOT related to terminal illness?
Medicare B- GW modifier
Billing for specialist in community for issue RELATED to terminal dx?
Specialist should bill hospice at previously agreed contracted rate
5 step process for hospice agency to appeal decision of an ADR (additional development request- a pre-payment review)
- redetermination by the Medicare administrative contractor (MAC)
- reconsideration by a qualified independent contractor (QIC)
- ALJ hearing
- Medicare Appeals Council review
- judicial review in Federal District Court.
What is the inpatient cap limit?
GIP plus respite days, to no more than 20% of the total hospice days for a hospice agency.
Boards answer for duration of bereavement support following a death?
12 months
What are Hospice Criteria for ALS?
Must meet criteria 1 OR 2
1) Critically impaired breathing capacity
FVC < 40% plus 2 additional signs (or 3 of the below if no FVC)
Dyspnea at rest, orthopnea, RR >20, paradoxical abdominal motion, weak cough
Reduced speech volume, frequent sleep awakening, daytime somnolence
Use of accessory respiratory muscles, sx of sleep disordered breathing
Unexplained headaches, confusion, anxiety, nausea
2) Severe nutritional deficiency
Dysphagia w/ progressive loss of at least 5% body weight (with or without a
feeding tube)
What are the Hospice Criteria for Cancer?
Must Meet Criteria 1 or 2
1) Disease with metastases at presentation
2) Progression from an earlier stage of disease to metastatic disease
with either
Continued decline in spite of therapy OR
Patient refuses further disease directed therapy
NOTE: Certain cancers (SCLC, brain cancer, pancreatic cancers) may be
hospice eligible without fulfilling other criteria in this section
Hospice Criteria for Dementia?
Must meet ALL Criteria 1-4
1) FAST 7 or beyond
2)Unable to ambulate, dress, bathe without assistance
3)Urinary and fecal incontinence (intermittent or constant)
4) No consistently meaningful verbal communication (<6 intelligible words)
PLUS, one of the following within the past 12 months
Aspiration pneumonia, pyelonephritis
Septicemia, recurrent fever (despite antibiotics)
Decubitus ulcers, stage 3-4
Serum albumin <2.5, > 10% weight loss over past 6 months
Hospice Criteria for Heart Disease
Must Meet 1 AND 2
1) Patient optimally tx for heart disease or is not a candidate for surgical
procedures (or refuses/cannot tolerate optimal medical or surgical
therapy)
2)CHF with NYHA Class IV or LVEF <20% (if TTE available)
Additional Supportive Documentation
TX resistant symptomatic SVT or ventricular arrhythmia
Hx cardiac arrest/resuscitation, or hx unexplained syncope
Brain embolism (cardiac origin)
Concomitant HIV disease
Hospice Criteria for HIV?
Hospice eligible if patient meets criteria 1 and 2
1) CD4+ <25 or 2+ assays with VL >100K plus one of following
CNS lymphoma, systemic lymphoma, PML
MAC, cryptosporidium, toxoplasmosis, Kaposi’s
Muscle wasting (loss of >10% body mass)
2) Decreased performance status (KFS <50%)
Additional Supportive Documentation
Chronic diarrhea (>1 year)
Concomitant active substance abuse
Persistent serum albumin <2.5
Age >50, advanced AIDS dementia
CHF (NYHA Class IV), advanced liver disease
Hospice Criteria for Liver Disease?
Hospice eligible if patient meets criteria 1 and 2
1) Patient has following labs
PTT >5s over control or INR>1.5
Serum albumin< 2.5
2) End stage liver disease present with one of the following
Refractory ascites, SBP, HRS
HE (refractory or non adherent), recurrent variceal bleeding
Additional Supportive Documentation
HCC, continued active alcoholism
Hep B, HCC (untreated)
Progressive malnutrition, muscle wasting with reduced endurance
Hospice Criteria for Lung Disease?
Hospice eligible if patient meets criteria 1 and 2
1) Severe chronic lung disease documented by BOTH a) and b)
Disabling dyspnea at rest (poorly or unresponsive to bronchodilators)
results in poor functional status (bed to chair existence)
Progression of end stage disease as evidence by increasing ER visits,
hospitalizations for pulmonary infections or increased doctor visits
2) Hypoxemic at rest on room air
pO2≤55 mmHg, O2 ≤88%, cO2≥55 mmHg (w/in 3 months)
Additional Supportive Documentation
Cor pulmonale/RHF, resting HR >100
Weight loss >10% over past 6 months
FEV1 <30% after BD (evidence of disabling dyspnea)
Documentation of serial decrease FEV1>40ml/year (evidence of progression)
Hospice Criteria for Acute Renal Disease?
Hospice eligible if meets criteria 1 and either 2,3,or 4
1) Patient not pursuing dialysis or renal transplant or is stopping HD
2) CrCl<10 (<15 if diabetes) or <15 w/CHF (<20 if diabetes)
3) Serum Cr>8 (>6 if diabetes)
4) GFR <20
Additional Supportive Documentation
Chronic lung disease, advanced heart or liver disease
Mechanical ventilation
AIDS, immunosuppression, malignancy
Albumin < 3.5, platelet <25K
DIC, GI bleeding, sepsis, cachexia
Hospice Criteria for Chronic Renal Failure?
Hospice eligible if meets criteria 1 and either 2,3,or 4
1) Patient not pursuing dialysis or renal transplant or is stopping HD
2) CrCl<10 (<15 if diabetes) or <15 w/CHF (<20 if diabetes)
3) Serum Cr>8 (>6 if diabetes)
4) Signs and symptoms of renal failure
Uremia, oliguria, HRS, fluid overload (not responsive to TX)
Uremic pericarditis, intractable hyperkalemia
Additional Supportive Documentation
GFR <10
Hospice Criteria for Stroke?
Hospice eligible if meets criteria 1 and 2
1) KPS or PPS <40%
2) Inability to maintain hydration and caloric intake with one of the below
Weight loss >10% over past 6 months or >7.5% over past 3 months
Albumin <2.5
Current hx of aspiration, not amenable to speech therapy
Declining calorie counts showing inadequate intake
Severe dysphagia preventing patient from being able to maintain
weight and patient does not want artificial hydration/nutrition
Hospice Criteria for Coma?
Hospice eligible with at least 3 of the following on day 3 s/p event
1) Abnormal brainstem response
2) Absent verbal response
3) Absent withdrawal response to pain
4) Serum Cr >1.5
Additional Supportive Documentation
Medical complications in context of progressive decline over past 12
months
Aspiration pneumonia, refractory stage 3-4 ulcers
Fevers despite antibiotics, pyelonephritis
General Decline LCD?
Worsening CLINICAL STATUS + SIGNS + SYMPTOMS+ LABS
Clinical Status
Recurrent or intractable
serious infections
Progressive malnutrition
Dysphagia→ recurrent
aspiration and poor oral
intake
Decreasing
albumin/cholesterol, >10%
weight loss over 6 months
(not due to reversible causes)
Decreasing LMAC, abdominal
girth (not due to reversible
causes)
Observation of ill-fitting
clothing, decreased skin
turgor, increase in skin folds
etc.
Decline in SBP <90 or
progressive postural
hypotension
Ascites
Venous, arterial, or
lymphatic obstruction due to
local progression/metastatic
disease
Edema
Pleural/pericardial effusion
Weakness
Change in level of
consciousness
Increasing pCO2 or
decreasing pO2 or SaO2
Increasing Ca2+, Cr, LFTs
Increasing tumor markers
Progressively
decreasing/increasing serum
Na+ or increasing K+
What factors are associated with a SHORTER hospice stay?
Diagnosis of heart failure, stroke, or renal failure
Or if referred from hospital
How can a physician bill Medicare Part A outside daily per diem rate?
Hospice billing office must submit CPT codes specific to service location and level of service
Any hospice eligibility visits are considered ADMINISTRATIVE and doctors cannot bill separately (this is under per diem rate)
Who and HOW can a physician bill for care plan oversight?
1) Physician must not be a medical director for the hospice that is providing the patient care
2) Physician must document
that he/she spent 30 minutes or more in a calendar month on CPO
3) Physician must have had face-to-face
contact with the patient in the last 6 months
4) CPO activities cannot be a part of follow-up to a
clinic or home visit..
