L31536 HOSPICE - LIVER DISEASE

 

 

Oversight Region

Region IV

 

11/29/2012

 

• 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.

o 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.

o 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.

o Coverage of hospice care for patients not meeting the criteria in this policy may be denied.

o However, some patients may not meet the criteria, yet still be appropriate for hospice care, because of other comorbidities or rapid decline.

o 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):

o The patient should show both:

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

 Serum albumin <2.5 gm/d1.

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

 Ascites, refractory to treatment or patient non-complaint.

 Spontaneous bacterial peritonitis.

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

 Hepatic encephalopathy, refractory to treatment, or patient non-complaint.

 Recurrent variceal bleeding, despite intensive therapy.

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

 progressive malnutrition

 muscle wasting with reduced strength and endurance

 continued active alcoholism (> 80 gm ethanol/day)

 hepatocellular carcinoma

 HBsAg (Hepatitis B) positivity

 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.

 

 

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

 

 

Documentations Requirements

 

• 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.

• Documentation certifying terminal status must contain enough information to confirm terminal status upon review.

o Documentation meeting the criteria outlined in the Indications and Limitations of Coverage and/or Medical Necessity section of this policy would meet this requirement.

• 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.

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

 

 

Sources of Information and Basis for Decision

 

Medical Guidelines for Determining Prognosis in Selected Non-Cancer Diseases, ©1996, National Hospice Organization

 

 

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