Hospice services are eligible for coverage when the following circumstances are documented:
- The physician has provided written certification that the patient has a terminal illness with a life expectancy of six months or less; and
- The patient will no longer benefit from curative therapies or has selected to receive hospice care rather than curative care; and
- If the hospice care is provided at home, a family member or friend is available to provide custodial care between visits of the hospice interdisciplinary team members.
Treatments of emergency conditions, such as a fracture or laceration requiring traditional curative care, while the patient is in the hospice setting, are eligible for coverage under applicable contract provision(s).
The following items, while possibly part of hospice services, are NOT eligible for separate coverage:
- Food or home delivered meals, such as Meals on Wheels,
- Homemaker or housekeeping services,
- Transportation services,
- Durable Medical Equipment,
- Respite Care services, such as hospitalization to provide care givers with a rest period, and
- Traditional curative care services for treatment of the terminal illness, condition, disease, or injury.
NOTE: Respite Care, in the home, is part of the Hospice Care Services provided and therefore does not warrant separate, additional reimbursement.
Palliative care and hospice programs are points on the continuum of comprehensive patient care. Hospice services should be available to patients who can no longer benefit from a curative treatment plan, but benefit from a palliative concept using methods of pain and symptom control, which enable the patient to live as comfortably as possible. More than 80% of hospice care hours are provided in patient's homes, thus substituting for more expensive hospitalizations. In 1995, hospices cared for about one out of every two cancer deaths in America. In 1998, the average length of hospice stay (LOS) was 51.3 days and the median was 25 days.
Disclaimer for coding information on Medical Policies
Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.
The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.
Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.