Hospice- Criteria and Services

Question 1

What predicts someone’s likelihood to enroll in Medicare Hospice?

Answer 1

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

Question 2

What is covered under the following in Medicare?

1) PART A
2) PART B
3) PART C
4) PART D

Answer 2

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

Question 3

What ECOG qualifies someone for hospice?

Answer 3

ECOG 2 or HIGHER

KPS/PPS 70 or lower

Question 4

What hospice team members are REQUIRED as defined by Medicare Hospice Benefit/COP?

Answer 4

1) Physician services
2) Nursing services
3) SW services
4) Bereavement counseling
5) Dietary counseling
6) Spiritual counseling

Question 5

Requirement for Continuous Care?

Answer 5

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)

Question 6

How frequently may a family access Respite Care? For how long?

Answer 6

Theoretically- more than once during a benefit period

Respite period CANNOT exceed 5 days each time

Question 7

What are the indications for GIP?

Answer 7

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

Question 8

What are the ONLY 3 reasons a patient can be discharged BY the hospice?

Answer 8

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

Question 9

How can a family appeal a hospice discharge?

Answer 9

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

Question 10

What 7 metrics are tracked by NQF for hospice agencies? (AKA Hospice Item Set or HQRP)

Answer 10

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

Question 11

Hospice use by different ethnicities

Answer 11

49.2% of white beneficiaries
40.2% of Hispanic
37.3% of African American
32% of Asian American

Question 12

How early can Narratives be completed prior to start of BP? COTI? F2F visit?

Answer 12

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

Question 13

Who can do a F2F visit?

Answer 13

MD or NP (NP must be employed by hospice)

CANNOT BE A PA

Question 14

SIA can be billed for which two types of visits? Maximum billable hours per day?

Answer 14

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

Question 15

What are the 3 situations where a hospice agency is required to issue an ABN (advanced beneficiary notice)?

Answer 15

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.”

Question 16

What is the next step after discharging patient for cause?

Answer 16

Notify the Medicare Administrative Contractor (MAC) and state survey agency.

Question 17

Billing code for an AOR not employed by hospice?

Answer 17

Medicare B- GV modifier

Question 18

Billing code for specialist in community for problem NOT related to terminal illness?

Answer 18

Medicare B- GW modifier

Question 19

Billing code for specialist in community for problem NOT related to terminal illness?

Answer 19

Medicare B- GW modifier

Question 20

Billing for specialist in community for issue RELATED to terminal dx?

Answer 20

Specialist should bill hospice at previously agreed contracted rate

Question 21

5 step process for hospice agency to appeal decision of an ADR (additional development request- a pre-payment review)

Answer 21

1. redetermination by the Medicare administrative contractor (MAC)
2. reconsideration by a qualified independent contractor (QIC)
3. ALJ hearing
4. Medicare Appeals Council review
5. judicial review in Federal District Court.

Question 22

What is the inpatient cap limit?

Answer 22

GIP plus respite days, to no more than 20% of the total hospice days for a hospice agency.

Question 23

Boards answer for duration of bereavement support following a death?

Answer 23

12 months

Question 24

What are Hospice Criteria for ALS?

Answer 24

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)

Question 25

What are the Hospice Criteria for Cancer?

Answer 25

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

Question 26

Hospice Criteria for Dementia?

Answer 26

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

Question 27

Hospice Criteria for Heart Disease

Answer 27

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

Question 28

Hospice Criteria for HIV?

Answer 28

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

Question 29

Hospice Criteria for Liver Disease?

Answer 29

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

Question 30

Hospice Criteria for Lung Disease?

Answer 30

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)

Question 31

Hospice Criteria for Acute Renal Disease?

Answer 31

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

Question 32

Hospice Criteria for Chronic Renal Failure?

Answer 32

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

Question 33

Hospice Criteria for Stroke?

Answer 33

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

Question 34

Hospice Criteria for Coma?

Answer 34

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

Question 35

General Decline LCD?

Answer 35

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+

Question 36

What factors are associated with a SHORTER hospice stay?

Answer 36

Diagnosis of heart failure, stroke, or renal failure

Or if referred from hospital

Question 37

How can a physician bill Medicare Part A outside daily per diem rate?

Answer 37

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)

Question 38

Who and HOW can a physician bill for care plan oversight?

Answer 38

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..