Quick reference for hospice admission guidelines

Determination of prognosis for:

ALS         Cancer           Decline in Clinical Status           Dementia                Heart Disease           HIV               Liver Disease            Pulmonary Disease          Renal Disease              Stroke and Coma

Revised Medicare Guidelines For Admission to Hospice (UniPolicy):
PDF      Word      Text

Official government website for Medicare

When is hospice care right for your patient?
The physician's role
How to refer a patient
The admission process
What hospice services are available
Reimbursement for physicians
Physician billing guidelines

When is Hospice Care Right for Your Patient?

When the patient has a limited prognosis. If your patient has a prognosis of a life limiting illness with diminishing results from radio-therapy or chemotherapy.

When the families' needs demand extra time from you. The lessening of curative therapy often calls for an increase in care for the terminally ill patient and their family. The hospice care team is on call 24 hours a day, 365 days a year providing patient and family care.

When the physician wants to guide palliative care. Hospice care is not a replacement for a trained physician but an extension of the physician's services. In addition it provides pain and symptom management for the patient and medical reports for the attending physician.

When supportive home care is needed. The hospice supportive care network includes counseling, social services, chaplain, and volunteer services as needed. Supportive home care relieves the anxieties of the patient and family while encouraging each patient to enjoy their daily lives.

What is the Role of the Physician?

The cooperation of the physician in the hospice process is a vital factor in the success of hospice.

• The patient's relationship with his/her physician remains the same under Iowa City Hospice's care.

• The physician approves any patient admission to Iowa City Hospice. The physician provides the necessary information about the patient and works out a proper care plan with an Iowa City Hospice Patient and Family Care Coordinator.

• The physician gives palliative orders. The physician gives orders for the patient's pain and symptom management in cooperation with the Iowa City Hospice team.

• The physician evaluates hospice effectiveness for each patient. The physician remains an active part of the hospice process by receiving health reports about the patient from Iowa City Hospice and directing the patient's plan of care.

• The physician bills each patient separately from Iowa City Hospice. The physician remains in control of his or her patient's care and is part of Iowa City Hospice's program, but continues to bill the patient separately.

How to Refer a Patient to Iowa City Hospice

Anyone can refer a patient to hospice. At Iowa City Hospice, 63% of the referrals come from physicians and hospital social workers while 23% are referred by family, friends or are self-referrals. The remaining patients are referred from community agencies and home health providers. Iowa City Hospice admits patients of any age with any diagnosis. Patients do not need a DNR status for hospice admission.

Iowa City Hospice will ask for the following information regarding the patient:

• admitting diagnosis and prognosis
• current medical findings
• orders for medications and treatment
• patient and family understanding of the disease and prognosis
• relevant patient and family information
• history and physical order for hospice care
• data to support 6 month prognosis

Once the patient is enrolled in Iowa City Hospice's program, the attending physician will be a primary resource on the patient's' medical condition and needs.

The Iowa City Hospice primary nurse will be in regular contact regarding symptom management, changes in the patient's condition, and the need for clinic or home visit follow-up.

The Admission Process

1. The physician provides the patient's name, address, age, present location, diagnosis, and estimated prognosis and suggests the family have an informational meeting with Iowa City Hospice staff.
2. Iowa City Hospice's Admissions Nurse will visit the patient and family to assess immediate needs, recommend an initial plan of care and obtain the patient's informed consent.
3. Hospice care can begin as soon as a workable plan is agreed on by the patient, the physician, and Iowa City Hospice.

What Services Are Available from Iowa City Hospice?

Iowa City Hospice offers all of the services listed below and others as appropriate. For specific details contact Iowa City Hospice.

Nurses are provided as often as necessary whether the patient is homebound or not.

Family counseling: Social Workers help the family cope with the stress that often accompanies terminal illness. They also address the family anxieties and treat the emotional focus of the patient prior to the onset of medical acuity.

Chaplain services are available if the patient or family request spiritual support.

Bereavement counseling: Family members can receive counseling up to 13 months following the patient's death in order to bring the family back to the mainstream of daily living and to prevent grief related illnesses. Ongoing counseling, support groups and educational activities are available not only to family members, but to anyone in Iowa City Hospice's 7-county service area for as long as needed.

Home health aides provide personal care for the patient.

Volunteers help with household chores, shop for and sit with the patient. Iowa City Hospice coordinates additional in-home support services as needed.

Reimbursement for Physicians

The attending physician is the physician designated by the patient to have the most significant role in his or her care. The attending physician continues to bill Medicare Part B for professional services--home, inpatient, or nursing home visits--in the usual manner, independent of the hospice benefit. Medications, laboratory tests, and other non-physician services required for the management of the terminal illness are paid for by Iowa City Hospice through the hospice benefit.

Attending physicians can bill for care plan oversight for hospice patients. Payment is available for one physician per month for oversight supervision involving 30 or minutes of the physician's time per month.

Payment under CPT code 99375 encompasses significantly complex medical management requiring the integration of new information into the plan of care or adjustments in medical therapy furnished by the physician. It identifies the coordination of care among practitioners as care plan oversight services. This excludes telephone calls to patients and family members (Federal Register, 1994).

Care plan oversight includes the following physician activities:

• development / revision of care plans
• review of subsequent reports of patient status and related laboratory studies
• coordination and communication (including telephone calls) with other health care professional involved in the patient's care (excluding telephone calls to patients and family members)
• adjustment and integration of medical treatments

Physician Billing Guidelines for Hospice Care

This table reflects the provision of care and services related to the terminal illness covered by the Hospice Medicare Benefit.

DESCRIPTION	BILL MEDICARE PART B	BILL HOSPICE* INTERMEDIARY PAYS HOSPICE	BILL HOSPICE COVERED UNDER HOSPICE BENEFIT
ATTENDING PHYSICIAN Professional Fee
COVERING PHYSICIAN Professional Fee
CONSULTING PHYSICIAN Professional Fee
X-RAYS Technical Component
X-RAYS Physician Component	attending	consulting
RADIATION THERAPY Technical Component
RADIATION THERAPY Physician Component	attending	consulting
LABS
CHEMOTHERAPY
PRESCRIPTION MEDICATIONS

* The Medicare intermediary pays the hospice an amount equivalent to 100% of allowable charges for those physician services furnished under arrangements with the hospice. Payment is then provided to the physician by the hospice. Billing through hospice is required when the patient is covered by the Hospice Medicare Benefit. A written agreement between the hospice and the covering (stand-in) or consulting physician is needed.

Attending Physician is the physician designated by the patient to have the most significant role in determinations and delivery of the individual's medical care.
Bill Medicare Part B.

Covering Physician is the physician who sees the patient on behalf of the Attending Physician as part of vacation coverage or on-call status.
Bill Hospice using HCFA 1500.

Consulting Physician is the physician who provides direct patient care to a hospice patient for a condition related to the terminal illness.
Bill Hospice using HCFA 1500.

Adapted with permission from Hope Hospice.