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Local Coverage Determination (LCD)

Hospice - Renal Care

L34559

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Proposed LCD
Proposed LCDs are works in progress that are available on the Medicare Coverage Database site for public review. Proposed LCDs are not necessarily a reflection of the current policies or practices of the contractor.

Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L34559
Original ICD-9 LCD ID
Not Applicable
LCD Title
Hospice - Renal Care
Proposed LCD in Comment Period
N/A
Source Proposed LCD
N/A
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 11/21/2024
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
N/A
Notice Period End Date
N/A

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Issue

Issue Description

This LCD outlines limited coverage for this service with specific details under Coverage Indications, Limitations and/or Medical Necessity.
Issue - Explanation of Change Between Proposed LCD and Final LCD

CMS National Coverage Policy

Title XVIII of the Social Security Act, §1861 (dd)(1) states the term "hospice care" means the services provided to a hospice patient.

Title XVIII of the Social Security Act, §1862 (a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Title XVIII of the Social Security Act, §1862 (a)(6) addresses items and services which constitute personal comfort items (except, in the case of hospice care, as is otherwise permitted).

Title XVIII of the Social Security Act, §1862 (a)(9) addresses items and services where such expenses are for custodial care (except in the case of hospice care, as is otherwise permitted).

Title XVIII of the Social Security Act, §1812 (a)(4) states in lieu of certain benefits, hospice care with respect to the individual during up to two periods of 90 days each and unlimited number of subsequent periods of 60 days each with respect to which the individual makes an election.

Title XVIII of the Social Security Act, §1813 (a)(4)(A)(i) addresses drugs and biologicals provided in a hospice program.

Title XVIII of the Social Security Act, §1814 (a)(7)(A)(i) addresses certifying the patient for hospice.

42 CFR §418 Hospice Care

CMS Internet-Only Manual, Pub. 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4, §60 Certification and Recertification by Physicians for Hospice Care

CMS Internet-Only Manual, Pub. 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Ch 5, §60 Hospice Defined, §60.1 Subdivision of Organizations as Hospices and §60.2 Arrangements by Hospices

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 9, §10 Requirements-General, §20.1 Timing and Content of Certification, §20.2.1 Hospice Election, §40 Benefit Coverage and §80 Hospice Pre-Election Evaluation and Counseling Services

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 11, §40 Other Services

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

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

End stage renal disease (ESRD) may support a prognosis of 6 months or less under many clinical scenarios. The identification of specific structural/functional impairments, together with any relevant activity limitations, should serve as the basis for palliative interventions and care planning. The structural and functional impairments associated with a primary diagnosis of ESRD are often complicated by comorbid and/or secondary conditions. Comorbid conditions affecting beneficiaries with ESRD are by definition distinct from the ESRD itself - examples include vascular disease manifested as coronary heart disease (CHD), peripheral vascular disease (PVD), and vascular dementia. Secondary conditions, on the other hand, are directly related to a primary condition. In the case of ESRD, examples include secondary hyperparathyroidism, calciphylaxis, nephrogenic systemic fibrosis, electrolyte abnormalities and anorexia. The important roles of comorbid and secondary conditions are described below in order to facilitate their recognition and assist providers in documenting their impact.

Medicare rules and regulations 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. For beneficiaries with ESRD the identification of relevant comorbid and secondary 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:

ESRD 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 - related to the secondary condition. The occurrence of secondary conditions in beneficiaries with ESRD is facilitated by the presence of impairments in such body functions as urinary excretory function, water, mineral and electrolyte function, and endocrine gland functions. Such functional impairments contribute to the increased incidence of secondary conditions such as hyperkalemia, fluid overload, and secondary hyperparathyroidism observed in Medicare beneficiaries with ESRD. 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, the combined effects of the ESRD and any secondary condition should be such that most beneficiaries with ESRD and similar impairments would have a prognosis of 6 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 - related to the comorbid condition. For example, a beneficiary with ESRD and clinically significant CHD would have specific impairments of cardiovascular structure/function (e.g., narrowing of coronary arteries, dyspnea, orthopnea, chest pain) which may or may not respond/be amenable to treatment. The identified impairments in cardiovascular structure/function may be associated with activity limitations (e.g., mobility, self-care). Ultimately, the combined effects of the ESRD and any comorbid condition should be such that most beneficiaries with ESRD and similar impairments would have a prognosis of 6 months or less.

The documentation of structural/functional impairments and activity limitations facilitates the selection of intervention strategies (palliative vs. long-term disease management/curative) and provides 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.
Summary of Evidence

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Analysis of Evidence (Rationale for Determination)

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Proposed Process Information

Synopsis of Changes
Changes Fields Changed
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Associated Information
Sources of Information
Bibliography
Open Meetings
Meeting Date Meeting States Meeting Information
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Contractor Advisory Committee (CAC) Meetings
Meeting Date Meeting States Meeting Information
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MAC Meeting Information URLs
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Proposed LCD Posting Date
Comment Period Start Date
Comment Period End Date
Reason for Proposed LCD
Requestor Information
This request was MAC initiated.
Requestor Name Requestor Letter
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Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code Description

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Revenue Codes

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CPT/HCPCS Codes

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ICD-10-CM Codes that Support Medical Necessity

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Group 1

Group 1 Paragraph:

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 Group 1 Codes:

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ICD-10-CM Codes that DO NOT Support Medical Necessity

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Group 1

Group 1 Paragraph:

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 Group 1 Codes:

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Additional ICD-10 Information

General Information

Associated Information

Documentation Requirements

Documentation must be legible, relevant and sufficient to justify the services billed. This documentation must be made available to the A/B HHH MAC upon request. 

The documentation in the hospice patient’s medical record should contain sufficient “clinical” information to support the certification or the individual as having a terminal illness with a life expectancy of 6 or fewer months, if the illness runs its normal course. 

For beneficiaries with ESRD, the identification of relevant comorbid and secondary 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.

Recertification for hospice care requires that the same standards be met as for initial certification.
Sources of Information
N/A
Bibliography

1. Murray AM, Arko C, Chen SC, Gilbertson DT, Moss AH. Use of hospice in the United States dialysis population. Clin J Am Soc Nephrol. 2006;1(6):1248-1255.

2. Daram SR, Cortese CM, Bastani B. Nephrogenic fibrosing dermopathy/nephrogenic systemic fibrosis: Report of a new case with literature review. Am J Kidney Dis. 2005;46(4):754-759.

3. Himmelfarb J. Core curriculum in nephrology: Hemodialysis complications. Am J Kidney Dis. 2005;45(6):1122-1131.

4. Moss AH, Holley JL, Davison SN, et al. Core curriculum in nephrology: Palliative care. Am J Kidney Dis. 2004;43(1):172-185.

5. Wiggins J. Core curriculum in nephrology: Geriatrics. Am J Kidney Dis. 2005;46(1):147-158.

 

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
11/21/2024 R13

Under CMS National Coverage Policy updated section headings and removed the regulation “CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 10, §40.2 HH PPS Claims” and placed it in the related Billing and Coding: Hospice - Renal Care A56545 article. Under Coverage Indications, Limitations and/or Medical Necessity removed verbiage in the first paragraph related to the International Classification of Functioning, Disability and Health (ICF) as it is no longer utilized. Under Bibliography removed fourth reference to ICF as it is no longer utilized, and changes were made to citations to reflect AMA citation guidelines. Formatting and typographical errors were corrected throughout the LCD.
  • Provider Education/Guidance
11/14/2019 R12

This LCD is being revised in order to adhere to CMS requirements per Chapter 13, Section 13.5.1 of the Program Integrity Manual, to remove all coding from LCDs. There has been no change in coverage with this LCD revision. CMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 11, §§30.2, 30.2.2, and 30.3 was removed from the CMS National Coverage Policy section of this LCD and placed in the related Billing and Coding: Hospice - Renal Care A56545 Article.
  • Provider Education/Guidance
05/16/2019 R11

All coding located in the Coding Information section has been moved into the related Billing and Coding: Hospice - Renal Care A56545 article and removed from the LCD. 

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.
  • Provider Education/Guidance
05/09/2019 R10

Under Bibliography changes were made to citations to reflect AMA citation guidelines. Typographical errors were corrected throughout the LCD. Acronyms were inserted where appropriate throughout the LCD
  • Provider Education/Guidance
10/01/2018 R9

Under ICD-10 Codes that Support Medical Necessity Group 1: Codes the following ICD-10 codes have been added: I13.2 and I13.11.This revision is due to the Annual ICD-10 Code Update and becomes effective October 1, 2018.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

 
  • Revisions Due To ICD-10-CM Code Changes
05/04/2017 R8 Under CMS National Coverage Policy added the citation “CMS Internet-Only Manual, Pub100-01, Medicare General Information, Eligibility, and Entitlement Manual, Ch 5, §§60, 60.1 and 60.2”.
  • Provider Education/Guidance
01/01/2017 R7 Under CPT/HCPCS Codes the description was revised for HCPCS code G0300. This revision is due to the 2017 Annual CPT/HCPCS Code Update and becomes effective 1/1/17.
  • Provider Education/Guidance
  • Revisions Due To CPT/HCPCS Code Changes
05/12/2016 R6 Under CMS National Coverage Policy added “is” to Title XVIII of the Social Security Act, §1862 (a)(6). The verbiage “with an” was deleted and revised to read “and” for Title XVIII of the Social Security Act, §1812 (a)(4). Section 20.2 was deleted from the following cited reference: CMS Internet –Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 9. Change Request 9369, Transmittal 3378 was deleted as this was manualized and is now found in the following manual citations: CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 10, §40.2 and CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 11, §§30.2, 30.2.2, 30.3. Under Sources of Information and Basis for Decision added author’s initial to the first cited reference, corrected the volume number for the last cited reference, and corrected capitalization for numerous journal titles.
  • Provider Education/Guidance
  • Typographical Error
  • Other (Formatting changes)
01/01/2016 R5 Under CMS National Coverage Policy section added CMS Internet-Only Manual, Pub 100-04 Medicare Claims Processing Manual, Change Request 9369, Transmittal 3378 dated October 16, 2015. Under CPT/HCPCS Codes section added HCPCS codes G0299 and G0300.
  • Revisions Due To CPT/HCPCS Code Changes
10/01/2015 R4 Per CMS Internet-Only Manual, Pub 100-08, Medicare Program Integrity Manual, Chapter 13, §13.1.3 LCDs consist of only “reasonable and necessary” information. All bill type and revenue codes have been removed.
  • Other (Bill type and/or revenue code removal)
10/01/2015 R3 Under CMS National Coverage Policy added reference to CMS Internet-Only Manual 100-02, Medicare benefit policy Manual, Chapter 11, Section 40.
Under Sources of Information and Basis for Decision corrected all sources to AMA formatting.
  • Provider Education/Guidance
  • Other (Annual Validation)
10/01/2015 R2 Under CMS National Coverage Policy in the Title XVIII's added "the term 'hospice care' means the services provided to a hospice patient"; “allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member”;“items and services which constitute personal comfort items (except, in the case of hospice care, as it otherwise permitted under paragraph”; “items and services where such expenses are for custodial care (except in the case of hospice care, as is otherwise permitted under paragraph”;“in lieu of certain other benefits, hospice care with respect to the individual during up to two periods of 90 days each with an unlimited number of subsequent periods of 60 days each with respect to which the individual makes an election under subsection”;“drugs and biologicals provided in a hospice program”; and “certifying the patient for hospice.” Added “Medicare General Information, Eligibility, and Entitlement Manual” to CMS Internet-Only Manual Pub 100-01. Added “Medicare Benefit Policy Manual” to CMS Internet-Only Manual Pub 100-02.
  • Other (Previous inadvertent removal of information)
10/01/2015 R1 Under CMS National Coverage Policy in the Title XVIII's removed "the term 'hospice care' means the services provided to a hospice patient"; “allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member”;“items and services which constitute personal comfort items (except, in the case of hospice care, as it otherwise permitted under paragraph”; “items and services where such expenses are for custodial care (except in the case of hospice care, as is otherwise permitted under paragraph”;“in lieu of certain other benefits, hospice care with respect to the individual during up to two periods of 90 days each with an unlimited number of subsequent periods of 60 days each with respect to which the individual makes an election under subsection”;“drugs and biologicals provided in a hospice program”; and “certifying the patient for hospice.” Under same section, added Hospice Care to 42 CFR, Part 418.
Removed "Medicare General Information, Eligibility, and Entitlement Manual" and "Medicare Benefit Policy Manual". Under Sources of Information and Basis for Decision updated references to follow AMA format. Made grammatical and punctuation corrections throughout policy.
  • Provider Education/Guidance
  • Other (Maintenance
    Annual Validation)
N/A

Associated Documents

Attachments
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Related National Coverage Documents
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Public Versions
Updated On Effective Dates Status
11/13/2024 11/21/2024 - N/A Currently in Effect You are here
11/09/2019 11/14/2019 - 11/20/2024 Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • Hospice Renal Care
  • Hospice
  • Renal Care
  • Renal

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