L31536-LCD

Automated World Health

Local Coverage Determination (LCD) for Hospice - Liver Disease (L31536)

Contractor Information

Contractor Name Palmetto GBA

Contractor Number 11004

Contractor Type HHH MAC

LCD Information

Document Information

LCD ID Number L31536

LCD Title Hospice - Liver Disease

Contractor's Determination Number J11AH-11-007-L

AMA CPT/ADA CDT Copyright Statement

Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

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South Carolina Tennessee Texas

Oversight Region Region IV

Original Determination Effective Date

For services performed on or after 01/24/2011 Original Determination Ending Date

Revision Effective Date

For services performed on or after 11/29/2012

Revision Ending Date

CMS National Coverage Policy

Title XVIII of the Social Security Act, §1861 (dd) the term "hospice care" means the services providered to a hospice patient

Title XVIII of the Social Security Act, §1862 (a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Title XVIII of the Social Security Act, §1862 (a)(1)(6), which consitute personal comfort items (except, in the case of hospice care, as it otherwise permitted under paragraph (1)(C)

Title XVIII of the Social Security Act, §1862 (a)(1)(9) expenses for custodial care (except in the case of hospice care, as is otherwise permitted under paragraph (1)(C)

Title XVIII of the Social Security Act, §1812 (a)(4) in lieu of certain benefits, hospice care with respect to the individual during up to two periods of 60 days each with respoce to which the individual makes an election under subsection (d)(1)

Title XVIII of the Social Security Act, §1813 (a)(4) drugs and biologicals provided in a hospice program Title XVIII of the Social Security Act, §1814 (a)(7) certifying the patient for hospice

42 CFR Chapter IV, Part 418

CMS Manual System, Pub. 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4,

§60

CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Chapter 9, §§10, 20, 40, and 80

CMS Manual System, Pub. 100-08 Medicare Program Integrity Manual, Chapter 13, §§13.1.1-13.13.14

Indications and Limitations of Coverage and/or Medical Necessity

Medicare coverage of hospice care depends upon a physician’s certification of an individual’s prognosis of a life expectancy of six months or less if the terminal illness runs its normal course. Recognizing that determination of life expectancy during the course of a terminal illness is difficult, this intermediary has established medical criteria for determining prognosis for non-cancer diagnoses. These criteria form a reasonable approach to the determination of life expectancy based on available research, and may be revised as more research is available.

Coverage of hospice care for patients not meeting the criteria in this policy may be denied. However, some patients may not meet the criteria, yet still be appropriate for hospice care, because of other comorbidities or rapid decline. Coverage for these patients may be approved on an individual consideration basis.

Patients will be considered to be in the terminal stage of liver disease (life expectancy of six months or less) if they meet the following criteria (1 and 2 must be present; factors from 3 will lend supporting documentation):

1. The patient should show both a and b:

a. Prothrombin time prolonged more than 5 seconds over control, or International Normalized Ratio (INR)> 1.5

b. Serum albumin <2.5 gm/d1

2. End stage liver disease is present and the patient shows at least one of the following:

a. ascites, refractory to treatment or patient non-complaint

b. spontaneous bacterial peritonitis

c. hepatorenal syndrome (elevated creatinine and BUN with oliguria (<400ml/day) and urine sodium concentration <10 mEq/l)

d. hepatic encephalopathy, refractory to treatment, or patient non-complaint

e. recurrent variceal bleeding, despite intensive therapy

3. Documentation of the following factors will support eligibility for hospice care:

a. progressive malnutrition

b. muscle wasting with reduced strength and endurance

c. continued active alcoholism (> 80 gm ethanol/day)

d. hepatocellular carcinoma

e. HBsAg (Hepatitis B) positivity

f. hepatitis C refractory to interferon treatment

Patients awaiting liver transplant who otherwise fit the above criteria may be certified for the Medicare hospice benefit, but if a donor organ is procured, the patient must be discharged from hospice.

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

081x Hospice (non-Hospital based) 082x Hospice (hospital based)

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

0651 Hospice Service - Routine Home Care 0652 Hospice Service - Continuous Home Care 0655 Hospice Service - Inpatient Respite Care

0656 Hospice Service - General Inpatient Care Non-Respite 0657 Hospice Service - Physician Services

CPT/HCPCS Codes

HCPCS codes for applicable physician services. XX000 Not Applicable

ICD-9 Codes that Support Medical Necessity

155.0 MALIGNANT NEOPLASM OF LIVER PRIMARY

571.2 ALCOHOLIC CIRRHOSIS OF LIVER

571.40 CHRONIC HEPATITIS UNSPECIFIED

571.41 CHRONIC PERSISTENT HEPATITIS

571.42 AUTOIMMUNE HEPATITIS

571.49 OTHER CHRONIC HEPATITIS

571.5 CIRRHOSIS OF LIVER WITHOUT ALCOHOL

571.6 BILIARY CIRRHOSIS

572.2 HEPATIC ENCEPHALOPATHY

572.4 HEPATORENAL SYNDROME

573.3 HEPATITIS UNSPECIFIED

573.5 HEPATOPULMONARY SYNDROME

Diagnoses that Support Medical Necessity

ICD-9 Codes that DO NOT Support Medical Necessity

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity

General Information

Documentations Requirements

1. Documentation supporting the medical necessity should be legible, maintained in the patient’s medical record, and must be made available to the A/B MAC upon request.

2. Documentation certifying terminal status must contain enough information to confirm terminal status upon review. Documentation meeting the criteria outlined in the Indications and Limitations of Coverage and/or Medical Necessity section of this policy would meet this requirement.

3. If the patient does not meet the criteria outlined in the Indications and Limitations of Coverage and/or Medical Necessity section of this policy, yet is deemed appropriate for hospice care, sufficient documentation of the patient’s condition that justifies terminal status, in the absence of meeting the criteria, would be necessary.

4. Recertification for hospice care requires that the same standards be met as for initial certification.

Appendices N/A

Utilization Guidelines N/A

Sources of Information and Basis for Decision

Consultants, and other Medicare Medical Directors Advisory Committee Meeting Notes This policy does not represent the sole opinion of the contractor or Contractor Medical Director. Although the final decision rest with the Intermediary, this policy was developed in cooperation with advisory groups, which includes representatives from the hospice provider community. Advisory committee meeting date:

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 12/09/2010

Revision History Number Revision #2, Effective 11/29/2012

Revision History Explanation Revision #2, 11/29/2012

Under CMS National Policy the following citation is no longer valid: CMS Manual System, Pub. 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4, §80 and CMS Manual System, Pub. 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5, §§60, 60.1 and 60.2. Under Documentation Requirements changed the word "Intermediary" to "A/B MAC." This revision becomes effective on 11/29/2012

Revision #1, 10/01/2011

Under ICD-9 Codes That Support Medical Necessity ICD-9 code 573.5 was added. This revision becomes effective 10/01/2011.

01/24/2011 - In accordance with Section 911 of the Medicare Modernization Act of 2003, Palmetto GBA Title 18 RHHI (00380) was removed from this LCD and implemented to Palmetto GBA J11 HH and H MAC (11004). Effective date of this Implementation is January 24, 2011.

Reason for Change Maintenance (annual review with new changes, formatting, etc.)