L31538 HOSPICE - RENAL CARE

 

Region IV J11AH-11-009-L 11/29/2012

 

• End stage renal disease (ESRD) may support a prognosis of six months or less under many clinical scenarios.

o The identification of specific structural/functional impairments, together with any relevant activity limitations, should serve as the basis for palliative interventions and care planning.

o The structural and functional impairments associated with a primary diagnosis of ESRD are often complicated by comorbid and/or secondary conditions.

o Comorbid conditions affecting beneficiaries with ESRD are by definition distinct from the ESRD itself- examples include vascular disease manifested as coronary heart disease (CHD), peripheral vascular disease (PVD), and vascular dementia.

o Secondary conditions on the other hand are directly related to a primary condition.

o In the case of ESRD, examples include secondary hyperparathyroidism, calciphylaxis,

nephrogenic systemic fibrosis, electrolyte abnormalities and anorexia.

o The important roles of comorbid and secondary conditions are described below in order to facilitate their recognition and assist providers in documenting their impact.

o Use of the International Classification of Functioning, Disability and Health (ICF) is suggested, but not required.

• Medicare rules and regulations require the documentation of sufficient “clinical information and other documentation” to support the certification of individuals as having a terminal illness with a life expectancy of 6 or fewer months, if the illness runs its normal course.

o For beneficiaries with ESRD the identification of relevant comorbid and secondary conditions, together with the identification and description of associated structural/functional impairments, activity limitations, and environmental factors would help establish hospice eligibility and maintain a beneficiary-centered plan of care.

 

• Secondary Conditions:

o ESRD may be complicated by secondary conditions.

o The significance of a given secondary condition is best described by defining the

structural/functional impairments - together with any limitation in activity - related to the

secondary condition.

o The occurrence of secondary conditions in beneficiaries with ESRD is facilitated by the presence of impairments in such body functions as urinary excretory function, water, mineral and electrolyte function, and endocrine gland functions.

o Such functional impairments contribute to the increased incidence of secondary conditions such as hyperkalemia, fluid overload, and secondary hyperparathyroidism observed in Medicare beneficiaries with ESRD. Secondary conditions themselves may be associated with a new set of structural/functional impairments that may or may not respond/be amenable to treatment.

 

o Ultimately, the combined effects of the ESRD and any secondary condition should be such that most beneficiaries with ESRD and similar impairments would have a prognosis of six months or less.

 

• Comorbid Conditions:

o The significance of a given comorbid condition is best described by defining the structural/functional impairments - together with any limitation in activity - related to the comorbid condition.

 For example a beneficiary with ESRD and clinically significant CHD would have specific impairments of cardiovascular structure/function (e.g., narrowing of coronary arteries, dyspnea, orthopnea, chest pain) which may or may not respond/be amenable to treatment.

 The identified impairments in cardiovascular structure/function may be associated with activity limitations (e.g., mobility, self-care).

 Ultimately, the combined effects of the ESRD and any comorbid condition should be such that most beneficiaries with ESRD and similar impairments would have a prognosis of six months or less.

o The documentation of structural/functional impairments and activity limitations facilitate the selection of intervention strategies (palliative vs. long-term disease management/curative) and provide objective criteria for determining the effects of such interventions.

 The documentation of these variables is thus essential in the determination of reasonable

and necessary Medicare Hospice Services.

 

 

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

 

CPT codes for applicable physician services

XX000 Not Applicable

 

 

ICD-9 Codes that Support Medical Necessity

 

403.11 HYPERTENSIVE CHRONIC KIDNEY DISEASE, BENIGN, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE

584.5 ACUTE KIDNEY FAILURE WITH LESION OF TUBULAR NECROSIS

584.6 ACUTE KIDNEY FAILURE WITH LESION OF RENAL CORTICAL NECROSIS

584.7 ACUTE KIDNEY FAILURE WITH LESION OF RENAL MEDULLARY [PAPILLARY] NECROSIS

584.8 ACUTE KIDNEY FAILURE WITH OTHER SPECIFIED PATHOLOGICAL LESION IN KIDNEY

584.9 ACUTE KIDNEY FAILURE, UNSPECIFIED

585.6 END STAGE RENAL DISEASE

586 RENAL FAILURE UNSPECIFIED

 

 

Documentations Requirements

 

• Documentation supporting the medical necessity should be legible, maintained in the patient’s medical record, and must be made available to the Intermediary upon request.

• The documentation in the hospice patient’s medical record should contain sufficient “clinical” information to support the certification or the individual as having a terminal illness with a life expectancy of 6 or fewer months, if the illness runs its normal course.

• For beneficiaries with ESRD the identification of relevant comorbid and secondary conditions, together with the identification and description of associated structural/functional impairments, activity limitations, and environmental factors would help establish hospice eligibility and maintain a beneficiary-centered plan of care.

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

 

 

Sources of Information and Basis for Decision

 

Anne M Murray, Cheryl Arko, Shu-Cheng Chen, et al. Use of Hospice in the United States Dialysis Population. Clin J Am Soc Nephrol 1:1248-1255, 2006l

 

Daram SR, Cortese CM and Bastani B. Nephrogenic fibrosing dermatopathy/nephrogenic systemic fibrosis: Report of a new case with literature review. American Journal of Kidney Diseases, Volume 46, Number 4, October 2005.

 

Himmelfarb J. Core curriculum in nephrology: Hemodialysis complications. American Journal of Kidney Diseases, Volume 45, Number 6, June 2005.

International Classification of Functioning, Disability and Health. Geneva: World Health Organization, 2001. Moss AH, Holley JL, Davison SN, et al. Core curriculum in nephrology: Palliative care. American Journal of

Kidney Diseases, Volume 43, Number 1, January 2004.

 

Wiggins J. Core curriculum in nephrology: Geriatrics. American Journal of Kidney Diseases, Volume 46, Number 1, July 2005.

 

CMS LCD HOSPICE - RENAL CARE