Frequently Asked Questions

1. How can you tell when a patient has six months or less to live in order to qualify for the Medicare hospice benefit?
2. What are hospice benefit periods?
3. How is the attending physician reimbursed?
4. Is hospice care and nursing facility care a duplication of services, ('double-dipping')?
5. What CPT codes should a physician use when seeing a hospice patient in the nursing facility setting?

The regulations state that a patient can qualify for hospice if the patient is in the last six months of life "if the terminal disease runs it's normal course."

No one has a "crystal ball". Therefore, HCFA has revised the benefit periods for recertification of the patient's terminality, if a disease does not run it's "normal course".

To help with prognostication of non-malignant terminal disease, the National Hospice Organization (NHO) published the GUIDELINES FOR PROGNOSIS OF SELECTED NON-MALIGNANT TERMINAL DISEASES. (Appendix F) These guidelines are available to address end-stage prognostication of Dementia, Heart Disease, Pulmonary Disease, Liver Disease, Renal Disease, Coma, HIV, ALS, and Stroke.

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In the past there were four benefit periods, (90, 60, 30 days, then a fourth period that was unlimited). At each period the physician recertified that the patient had 6 months or less to live. Many patients had entered their 4th benefit period and were in fear of losing their hospice benefits, if they were to remain on hospice till they died.

Since the end of 1997, the benefit periods have been revised. Now the patient has 90, 90, then continuous 60 day benefit periods for physician recertification of terminality. For example, if a patient improves and is not felt to be terminal at the end of the 2nd benefit period, then the patient can come off of hospice care and be restarted when the patient's prognosis worsens again.

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If the attending physician is not salaried by the hospice that is caring for that patient, Medicare is billed for the level of service provided.

If the physician is employed by the hospice caring for that patient, the hospice is billed for the level of service provided.

If the physician is salaried by a different hospice, and not by the hospice caring for the patient, Medicare is billed for the level of service provided.

If an associate sees the patient, he/she must bill Medicare or the hospice under the primary care physician (attending physician of record) name and provider number and then be reimbursed by the physician. HCFA receives a record of the name of each attending physician for each hospice patient.

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Hospice began as caring for the dying patient at home. The family would provide the daily care for the patient, bathing, feeding, toileting, giving medicine, etc. Hospice would provide specialized services of pain management, non-pain symptom management, psychosocial, spiritual, and bereavement care for up to one year. Literature has established the value-added benefit of hospice to improve the quality of end-of-life care in this setting.

In 1986, the nursing home/facility was recognized as a surrogate home for America's elderly, and that hospice care was a patient right in this new home setting. Now the nursing facility provides the daily care for the patient, i.e., bathing, feeding, toileting, giving medicine, etc. Hospice would provide the same service as in any other home setting. The affects on the quality of end-of-life care in this setting have not been published.

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According to the Health Care Financing Administration and American Medical Association's CPT Information Services, "there are no specific CPT codes for evaluation and management services provided by a physician to a patient receiving hospice care in any location. When a Medicare beneficiary elects the hospice benefit, Medicare pays the hospice for all services related to the terminal illness through four set per diem rates. The exception to this is physician services. General supervisory services and participation in the establishment, review, and update of plans of care provided by the hospice medical director or a physician member of the hospice interdisciplinary team are included in this hospice per diem. This would include evaluation and management services provided by a physician employed by, or providing services under arrangement with, the hospice."

"Medicare hospice regulations, at 42 CFR 418.304(c), state that services of the patient's attending physician, who is not employed by the hospice or providing services under arrangements with the hospice, are not considered hospice services. These services are billed directly to Medicare Part B according to procedures established in 42 CFR 405 subparts D and E. When provided by an attending physician, as described above, evaluation and management services provided to hospice patients would be billed in the following manner:

• If the evaluation & management services are provided to a hospice patient that is residing in a nursing facility, then the subsequent nursing facility care codes are billed (99301-99316 series).
• If the evaluation & management services are provided to a hospice patient in their private residence, then the home services codes are billed (99341-99350 series). The physician must provide the evaluation & management services in the patient's home in order for these codes to be billed.
• If the evaluation and management services are provided to a patient in a board and care type facility, including a hospice residential facility, then domiciliary/rest home codes are billed (99321-99333 series). Again, these services must be provided in the facility in order for the domiciliary/rest home codes to be billed."