Case Review Criteria for Hospice

Medicare Quality Improvement Organization (QIO) review of a termination of service appeal focuses on the medical necessity of the services being rendered and the appropriateness of the setting. The information included in this section may be found in the Centers for Medicare & Medicaid Services' (CMS) Hospice Manual and serves as a general guideline for Medicare QIO appeal determinations. A decision as to whether or not services should be covered by Medicare must be made based on thorough analysis of the patient's condition and individualized need for care.

Chapter II. Available online at http://cms.hhs.gov/manuals/PBM/list.asp.
Basic Information Regarding Hospice Coverage
Covered Hospice Services
Counseling
Home Health Aide and Homemaker
Medical Social Services
Nursing Care
Nurse Practitioner
Physician
Short-Term General Inpatient Care
Special Modalities
Therapy – Physical, Occupational and Speech-Language Pathology
Other Items and Services

Basic Information Regarding Hospice Coverage

• entitled to Part A of Medicare, and
• certified as being terminally ill.
  An individual is considered to be terminally ill if the individual has a medical prognosis that his or her life expectancy is six months or less if the illness runs its normal course.

A hospice may discharge a patient if:

• it discovers that the patient is not terminally ill, or
• the patient moves out of the service area.

To be covered, services must be:

• consistent with the plan of care, and
• reasonable and necessary for the palliation or management of the terminal illness and related conditions.

General coverage under Medicare is reinstated at the time the patient revokes the benefit or is discharged. Upon revoking the election of Medicare coverage of hospice care for a particular election period, an individual resumes Medicare coverage of the benefits waived when hospice care was elected. An individual may at any time elect to receive hospice coverage for any other hospice election periods for which he/she is eligible.

Covered Hospice Services

In general, the services must be related to the palliation or management of the patient's terminal illness, symptom control, or maintainenance of activities of daily living and basic functional skills.

All services must be performed by appropriately qualified personnel, but it is the nature of the service, rather than the qualification of the person who provides it, that determines the coverage category of the service. The following services are covered hospice services.

•  Counseling Services

Counseling, including dietary counseling, may be provided both for the purpose of training the individual's family or other caregiver to provide care and for the purpose of helping the individual and those caring for him or her to adjust to the individual's approaching death.

•  Home Health Aide and Homemaker Services

Home health aides may provide personal care services. Aides also may perform household services to maintain a safe and sanitary environment in areas of the home used by the patient, such as changing the bed or light cleaning and laundering essential to the comfort and cleanliness of the patient. Aide services must be provided under the general supervision of a registered nurse. Homemaker services may include assistance in personal care, maintenance of a safe and healthy environment and services to enable the individual to carry out the plan of care.

•  Medical Social Services

Medical social services include counseling and assessment of the social and emotional factors related to the patient's illness, need for care and response to treatment.

•  Nursing Care

Nursing care includes skilled observation, monitoring (when necessary) and skilled care needed to control pain and other symptoms.

•  Nurse Practitioner Services

Medicare allows a nurse practitioner to serve as a hospice beneficiary's attending physician; however, a physician will be required to certify the terminal illness and six-month prognosis.

•  Physicians' Services

Physicians' services include certifying a beneficiary's terminal illness and oversight of the care plan.

•  Short-Term General Inpatient Care

General inpatient care may be required for procedures necessary for pain control or acute or chronic symptom management that cannot feasibly be provided in other settings. Short-term inpatient care may be provided in a participating hospice inpatient unit, or a participating SNF or NF that additionally meets the special hospice standards regarding patient and staffing areas. Skilled nursing care may be needed by a patient whose home support has broken down if this breakdown makes it no longer feasible to furnish needed care in the home setting. Services provided in an inpatient setting must conform to the written plan of care. An example of appropriate general inpatient care would be a patient in need of medication adjustment, observation or other stabilizing treatment, such as psychosocial monitoring, or a patient whose family is unwilling to permit needed care to be furnished in the home.

•  Short-Term General Inpatient Respite Care

Respite care is short-term inpatient care provided to the individual only when necessary to relieve the family members or other persons caring for the individual at home. Respite care may be provided only on an occasional basis and may not be reimbursed for more than five consecutive days at a time.

•  Special Modalities

Chemotherapy, radiation therapy and other modalities may be used for palliative purposes if determined that these services are needed for palliation. This determination is based on the patient's condition and the physician's care-giving philosophy.

•  Therapy — Physical, Occupational and Speech-Language Pathology Services

Therapy and speech-language pathology services may be provided for purposes of symptom control or to enable the individual to maintain activities of daily living and basic functional skills.

The hospice is responsible for providing any and all services indicated in the plan of care as necessary for the palliation and management of the terminal illness and related conditions. For example, when the hospice determines that a patient's condition has worsened and has become medically unstable, an inpatient stay will be necessary for proper palliation and management of the patient's fragile condition, and the patient will need to be transported to the hospital by ambulance. In this case, the ambulance service becomes a covered hospice service.