L31540-LCD

Automated World Health

Local Coverage Determination (LCD) for Hospice Cardiopulmonary Conditions (L31540)

Contractor Information

Contractor Name Palmetto GBA

Contractor Number 11004

Contractor Type HHH MAC

LCD Information

Document Information

LCD ID Number L31540

LCD Title Hospice Cardiopulmonary Conditions

Contractor's Determination Number J11AH-11-011-L

AMA CPT/ADA CDT Copyright Statement

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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 11/16/2012

Revision Ending Date

CMS National Coverage Policy

Title XVIII of the Social Security Act, §§1812(a)(4), 1813(a)(4), 1814(a)(7) and (i), 1862(a)(1)(A), (6) and (9), 1861(dd)

42 CFR Chapter IV, Part 418

CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Chapter 9, §§10, 20, 30, 40, 50, 60, 70 and

CMS Manual System, Pub. 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 1,

§10.1

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

§§60 and 80

CMS Manual System, Pub. 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5,

§§60.1 and 60.2

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

Federal Register, Volume 70, No. 224, dated Tuesday, November 22, 2005, page 70537.

Indications and Limitations of Coverage and/or Medical Necessity

Cardiopulmonary conditions are associated with impairments, activity limitations, and disability. Their impact on any given individual depends on the individual’s over-all health status. Health status mediates the much studied relationship between ICD-9-CM diagnosis and care outcomes. Health status includes environmental factors, such as the availability of palliative care services. The objective of this policy is to present a framework for identifying, documenting, and communicating the unique health care needs of individuals with cardiopulmonary conditions and thus promote the over-all goal of the right care for every person, every time.

Cardiopulmonary conditions may support a prognosis of six months or less under many clinical scenarios. Medicare rules and regulations addressing hospice services 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. The identification of specific structural/functional impairments, together with any relevant activity limitations, should serve as the basis for palliative interventions and care-planning. Use of the International Classification of Functioning, Disability and Health (ICF) to help identify and document the unique service needs of individuals with cardiopulmonary conditions is suggested, but not required.

The health status changes associated with cardiopulmonary conditions can be characterized using categories contained in the ICF. The ICF contains domains (e.g., structures of cardiovascular and respiratory systems, functions of the cardiovascular and respiratory system, communication, mobility, and self-care) that allow for a comprehensive description of an individual’s health status and service needs. Information addressing relevant ICF categories, defined within each of these domains, should form the core of the clinical record and be incorporated into the care plan, as appropriate.

Additionally the care plan may be impacted by relevant secondary and/or comorbid conditions. Secondary conditions are directly related to a primary condition. In the case of cardiopulmonary conditions, examples of secondary conditions could include delirium, pneumonia, stasis ulcers and pressure ulcers. Comorbid conditions affecting beneficiaries with cardiopulmonary conditions are, by definition, distinct from the primary condition itself. An example of a comorbid condition would be End Stage Renal Disease (ESRD).

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

Cardiopulmonary conditions may be complicated by secondary conditions. The significance of a given secondary condition is best described by defining the structural/functional impairments - together with any limitation in activity and restriction in participation - related to the secondary condition. The occurrence of secondary conditions in beneficiaries with cardiopulmonary conditions results from the presence of impairments in such body functions as heart/respiratory rate and rhythm, contraction force of ventricular muscles, blood supply to the

heart, sleep functions, and depth of respiration. These impairments contribute to the increased incidence of secondary conditions such as delirium, pneumonia, stasis ulcers and pressure ulcers observed in Medicare beneficiaries with cardiopulmonary conditions. Secondary conditions themselves may be associated with a new set of structural/functional impairments that may or may not respond/be amenable to treatment.

Ultimately, in order to support a hospice plan of care, the combined effects of the primary cardiopulmonary condition and any identified secondary condition(s) should be such that most beneficiaries with the identified impairments would have a prognosis of six months or less.

Comorbid Conditions:

The significance of a given comorbid condition is best described by defining the structural/functional impairments

- together with any limitation in activity and restriction in participation - related to the comorbid condition. For example a beneficiary with a primary cardiopulmonary condition and ESRD could have specific ESRD-related impairments of water, mineral and electrolyte balance functions coexisting with the cardiopulmonary impairments associated with the primary cardiopulmonary condition (e.g., Aortic Stenosis, Chronic Obstructive Pulmonary Disease, or Heart Failure)

Ultimately, in order to support a hospice plan of care, the combined effects of the primary cardiopulmonary condition and any identified comorbid condition(s) should be such that most beneficiaries with the identified impairments would have a prognosis of six months or less.

The documentation of structural/functional impairments and activity limitations facilitate the selection of the most appropriate intervention strategies (palliative/hospice vs. long-term disease management) 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.

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

While there are no specific ICD-9-CM codes for end stage cardiopulmonary conditions, the ICD-9-CM code describing the most relevant illness, disorder, or injury contributing to the prognosis of six months or less should be coded.

XX000 Not Applicable

Diagnoses that Support Medical Necessity

N/A

ICD-9 Codes that DO NOT Support Medical Necessity N/A

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

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

Documentations Requirements

Documentation certifying terminal status must contain enough information to confirm terminal status upon review. Documentation meeting the criteria listed under the Indications and Limitations of Coverage and/or Medical Necessity section of this LCD would contribute to this requirement. Recertification for hospice care requires that the same standards be met as for the initial certification.

Documentation should be legible and made available to the A/B MAC upon request.

Appendices N/A

Utilization Guidelines N/A

Sources of Information and Basis for Decision

Carabello B. Clinical Practice.Aortic Stenosis. N Engl J Med - 28-FEB-2002; 346(9): 677-82

Del Fabbro E. Symptom Control in Palliative Care – Part III: Dyspnea and Delirium - J Palliat Med - 01-APR-2006; 9(2): 422-36

International Classification of Functioning, Disability and Health. Geneva: World Health Organization, 2001. Rich MW. Heart Failure in Older Adults. Med Clin North Am - 01-SEP-2006; 90(5): 863-85

Stuart B. Palliative Care and Hospice in Advanced Heart Failure. J Palliat Med - 01-FEB-2007; 10(1): 210-28 Advisory Committee Meeting Notes This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the Intermediary, this policy was developed in cooperation

with advisory groups, which include representatives from the affected 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 #1, 11/16/2012

Revision History Explanation Revision #1, 11/16/2012

Under Documentation Requirements added, "Documentation should be legible and submitted to the A/B MAC upon request." Annual Review completed. This revision becomes effective 11/16/2012.

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.)