L31540 HOSPICE CARDIOPULMONARY CONDITIONS

 

 

Region IV J11AH-11-011-L

 

11/16/2012

 

• Cardiopulmonary conditions are associated with impairments, activity limitations, and disability.

o Their impact on any given individual depends on the individual’s over-all health status.

o Health status mediates the much studied relationship between ICD-9-CM diagnosis and care outcomes.

o Health status includes environmental factors, such as the availability of palliative care services.

o 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.

o 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.

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 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.

o 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.

o 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.

o Secondary conditions are directly related to a primary condition.

o In the case of cardiopulmonary conditions, examples of secondary conditions could include delirium, pneumonia, stasis ulcers and pressure ulcers.

o Comorbid conditions affecting beneficiaries with cardiopulmonary conditions are, by definition, distinct from the primary condition itself.

o 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.

o 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.

o 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.

o 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.

 Depth of respiration.

o 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.

o 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.

o 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

 Aortic Stenosis

 Chronic Obstructive Pulmonary Disease

 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.

o 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

 

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

 

 

Documentations Requirements

 

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

o 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.

o 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.

 

 

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

 

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