BlueCross and BlueShield of Montana Medical Policy/Codes
Hospice
Chapter: Administrative
Current Effective Date: December 27, 2013
Original Effective Date: December 27, 2013
Publish Date: December 27, 2013
Description

The National Hospice Organization (NHO) defines Hospice as "a medically-directed nurse-coordinated program providing a continuum of home and inpatient care for the terminally ill patient and family.  It employs interdisciplinary team acting under the direction of an autonomous hospice administration.  The program provides palliative and supportive care to meet the special needs arising out of the physical, emotional, spiritual, social, and economic stresses that are experienced during the final stages of illness and during dying and bereavement."

The hospice can be a:

  • Free-standing dedicated facility; or
  • Ward or collection of beds in a hospital or nursing home; or
  • Visiting program offered in the home of the patient.

All members of the hospice interdisciplinary team provide their own expertise.  These members are:

  • Attending and/or Hospice Physician(s); and
  • Nurse Coordinator and Nursing Staff; and
  • Psychosocial Worker; and
  • Dietitians or Nutritionists; and
  • Respiratory, Speech, Physical and/or Occupational Therapist(s); and
  • Volunteer; and
  • Chaplain; and
  • Pharmacist.

Services provided under the hospice care program include:

  • Physician visits; and
  • Nursing services; skilled and non-skilled; and
  • Pain Management services; and
  • Medications; and
  • Dietary counseling; and
  • Respiratory, Speech, Physical, and Occupational Therapy; and
  • Medical Supplies; and
  • Social and Spiritual services.
Policy

Each benefit plan or contract defines which services are covered, which are excluded, and which are subject to dollar caps or other limits.  Members and their providers have the responsibility for consulting the member's benefit plan or contract to determine if there is any exclusion or other benefit limitations applicable to this service or supply.  If there is a discrepancy between a Medical Policy and a member's benefit plan or contract, the benefit plan or contract will govern.

Coverage

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.

Rationale

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.

Coding

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. 

ICD-9 Codes

Refer to the ICD-9-CM manual.

ICD-10 Codes

Refer to the ICD-9-CM manual.

Procedural Codes: G0151, G0152, G0157, G0158, G0159, G0160, G0337, S0271, S9126, S9125, G0154, G0155, G0156, G0158, G0162, G0163, G0164, G0180, G0181, G0182, Q5001, Q5002, Q5003, Q5004, Q5005, Q5006, Q5007, Q5008, Q5009, Q5010
References
  1. Berkow, Robert M.D., and Andrew J. Fletcher, M.B., B.Chir, eds. 1992 The Merck Manual, 17th edition New Jersey: Merck & C., Inc.:571-2.
  2. "Guidelines for the Medical Management of the Home Care Patient" AMA Practice Parameters (CD ROM) American Society of Plastic and Reconstructive Surgeons, Inc. (1992 January): 1-25.
  3. Sulmasy, D.P., et al. "The quality of mercy. Caring for patients with 'do not resuscitate' orders" Journal of the American Medical Association (1992 February 5) 267(5): 682-6.
  4. Anonymous "Guidelines for the medical management of the home-care
  5. Patient American Medical Association Home Care Advisory Panel" Archives of Family Medicine (1993 February) 2(2): 194–206.
  6. "Care and Management of the Dying" 1991 Scientific American Medicine (CD ROM) Chapter IV (1994 December): 5.
  7. "Principles of Cancer Patient Management" 1991 Scientific American Medicine (CD ROM) Chapter IV (1994 December): 13-4.
  8. AMA Council on Scientific Affairs "Good care of the dying patient" Journal of the American Medical Association (1996 February 14) 275(60): 474–8.
  9. Frantz, T.T., et al. "Factors in hospice patients' length of stay." American Journal of Hospice and Palliative Care (1999 March-April) 16(2): 449-54.
  10. Emaunel, E.J., et al. "Assistance from family members, friends, paid care givers, and volunteers in the care of terminally ill patients." New England Journal of Medicine (1999 September 23) 341(13): 956-63.
  11. Klopfenstein, K.J. "Adolescents, cancer, and hospice" Adolescent Medicine (1999 October) 10(3): 437-43.
  12. Hospice Foundation of America "What is Hospice?" (1999): 1-2. (Web Site): http://www.hospicefoundation.org/virtual_html/whtis.htm .
  13. National Hospice and Palliative Care Organization "General Information" and "Hospice Fact Sheet" (1996-2000): 1-5 and 1-4. (Web Site): http://www.nhpco.org/general.
  14. Hospice Net - Death and Dying "The Hospice Concept" and "The Hospice Team" (2000): 1-2 and 1. (Web Site): http://www.hospicenet.org .
History
December 2013  New 2013 BCBSMT medical policy.
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Hospice