for healthcare providers

Who is eligible for the Medicare hospice benefit?

A patient is eligible who:

• has Medicare Part A.
• is considered by the patient’s physician to be within 6 months of death if the disease runs its normal course.
• has chosen to focus medical care on comfort, forgoing curative therapies.

The patient need not have pain or otherwise be suffering. There is no requirement to decline resuscitative efforts.

Levels of care and reimbursement?

Reimbursement is per diem for 1 of 4 levels of care and includes the personal services of a licensed nurse, home health aide, social worker and spiritual care coordinator. Coverage includes all medications for comfort and treatment of the hospice diagnosis, durable medical equipment such as a hospital bed, oxygen, a wheelchair and the services of a dietician if needed. Direct clinical care by Good Sam’s full-time physician is available.

The 4 levels of care are:

• Routine care: Delivered at the patient’s residence.
• Continuous care: Brief, intense services at the place of residence with a licensed nurse who is present continuously at a time of crisis, such as severe new or exacerbated symptoms or caregiver loss or breakdown.
• Inpatient care: Brief, intense services provided in a hospital, free-standing inpatient hospice, long-term acute care hospital or skilled nursing facility for severe symptoms that cannot be controlled in the home setting or for caregiver loss or breakdown.
• Respite care: Five days of care in each certification period in a contracted appropriate facility.
  

How are physicians involved in hospice care?

The referring physician may be the attending physician or another specialist, such as a hospitalist, who estimates that the patient’s prognosis is appropriately limited and who discusses the referral with the patient.

The attending physician may choose to have intense or minimal involvement with the hospice patient. For necessary care related to the hospice diagnosis, the attending physician may bill Medicare Part B for evaluation and management (E and M) services with the code GV. However, Medicare does not cover ancillary costs such as laboratory and radiology. Prior to the need for these services, ancillary costs can be negotiated with the hospice. Similarly, referrals to consultants may not be reimbursed unless prearranged with the hospice, which may agree to provide payment.

E and M services provided by the attending physician but not related to the hospice diagnosis are covered when billed to Medicare Part B with the code GW or the condition code 07.

If ever in doubt about coverage of services by Medicare, the hospice team is always available to advise and collaborate.

Good Sam keeps the attending physician’s office appraised of changes in the patient’s status on a regular basis and welcomes collaboration in the patient’s care. The attending physician typically signs the death certificate, but our medical director is available if needed.

Good Sam’s medical director also provides administrative and educational services to the hospice team and attends the multidisciplinary team conference every 14 days as the required physician member. Our medical director attests to each patient’s eligibility for hospice initially and at each recertification period. The first 2 certification periods are 90 days each; subsequent periods are 60 days.

How is prognosis determined for the purpose of hospice eligibility?

It is said that if a doctor would not be surprised to learn that a particular patient has died, it would be appropriate to at least consider a hospice referral.

Hospice eligibility depends on a prognosis of 6 months or less if the disease runs its natural or expected course. Recently, limited studies indicate that at least in certain disease states, palliative care itself may be a disease modifier and extend the lifespan. Although far from precise, prognosis in malignant disease has been more intensely studied and accepted with less questioning than prognosis in chronic nonmalignant but fatal conditions such as the neurodegenerative disorders; AIDS; severe developmental disabilities of childhood; and chronic cardiac, pulmonary, liver, and kidney diseases.

Fear of being accused of Medicare fraud by attesting incorrectly to a limited prognosis probably keeps many honest and caring physicians from appropriate, timely referral for the hospice benefits to which patients are entitled. However, the Medicare Claims Processing Manual, Chapter 11 advises fiscal intermediaries, “It should be noted that predicting life expectancy is not always exact.” Incorrect prognoses made in good faith do not serve as the basis for fraud investigations.

A physician who is considering a hospice referral but is unsure of prognosis may, if the patient agrees, consult hospice for an opinion about eligibility. If the patient is not eligible for hospice, a recommendation for other care options may result.

Who provides the direct hospice care?

Licensed nurses, home health aides, social workers, dieticians, spiritual and bereavement counselors, and volunteers are all active in hospice care. Good Sam’s medical director is available for consultation with attending and consulting physicians. The hospice physician is directly involved in the clinical care of complex issues or becomes involved at the patient’s or family’s request. The consultant pharmacist does not provide direct patient care but is an invaluable aid when parenteral opioids or sedatives are being considered or when the usual routes of administration are unavailable and special compounding provides alternatives.

How is bereavement addressed?

Medicare requires that for a minimum of 13 months following the patient’s death, members of the hospice staff keep in contact with the bereaved and provide or refer to professional counseling those whose grief seems unusually severe or unremitting. Loved ones, in addition to family and significant others, might include nursing home nurses and aides, private sitters, and dear friends. Good Sam participates in community bereavement activities as well.

Where do nurse practitioners fit in?

A nurse practitioner may serve as an attending for Medicare purposes but is not currently able to certify a patient’s limited prognosis. However, a revision to allow certification by a nurse practitioner is up for comment. A nurse practitioner may make the face-to-face home visit upon which the physician bases recertification for hospice patients who have passed the first 6 months of the hospice benefit.

What about Palliative Care Options?

After nearly three decades of serving our community, Good Sam has become synonymous with compassionate, expert care when it matters most. In alignment with our mission to affirm life in the midst of illness and honor what matters most to each patient and family served, Good Sam has incorporated a Palliative Care program designed to address critical gaps in care and help reduce unnecessary suffering.

Leveraging Good Sam’s commitment to clinical excellence and solid reputation, the new Palliative Care program will allow earlier access to an experienced team well-versed in walking alongside patients and families in challenging times. For more information click the button below.