Local Coverage Determination (LCD)

Hospice Cardiopulmonary Conditions

L34548

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Contractor Information

Contractor Name	Contract Type	Contract Number	Jurisdiction	States
Palmetto GBA	A and B and HHH MAC	11004 - HHH MAC	J - M	Alabama Arkansas Florida Georgia Illinois Indiana Kentucky Louisiana Mississippi New Mexico North Carolina Ohio Oklahoma South Carolina Tennessee Texas

LCD Information

Document Information

LCD ID
L34548

LCD Title
Hospice Cardiopulmonary Conditions

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 03/21/2024

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.

CMS National Coverage Policy

Title XVIII of the Social Security Act, §1812(a)(4) states in lieu of certain other benefits, hospice care with respect to the individual during up to 2 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.

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

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

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

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) constitutes 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 expenses for custodial care (except, in the case of hospice care, as is otherwise permitted).

42 CFR, Part 418 Hospice Care

CMS Internet-Only Manual, Pub. 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 1, §10.1 Hospital Insurance (Part A) for Inpatient Hospital, Hospice, Home Health, and Skilled Nursing Facility (SNF) Services - A Brief Description

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 and §80 Summary Table for Certifications/Recertifications

CMS Internet-Only Manual, Pub. 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5, §60 Hospice Defined

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 9, §10 Requirements - General, §20.1 Timing and Content of Certification, §30 Coinsurance, §40 Benefit Coverage, §50 Limitation on Liability for Certain Hospice Coverage Denials, §60 Provision of Hospice Services to Medicare/Veteran's Eligible Beneficiaries, §70 Hospice Contracts with an Entity for Services not Considered Hospice Services, and §80 Hospice Pre-Election Evaluation and Counseling Services

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Cardiopulmonary conditions are associated with impairments, activity limitations, and disability. Their impact on any given individual depends on the individual’s overall health status. Health status includes measures of functioning, physical illness, and mental well-being, as well as, environmental factors, such as the availability of palliative care services. 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 overall goal of the appropriate care for every person, every time.

Cardiopulmonary conditions may support a prognosis of 6 months or less under many clinical scenarios. 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. The identification of specific structural/functional impairments, together with any relevant activity limitations, should serve as the basis for palliative interventions and care planning.

Additionally, the care plan may be impacted by relevant secondary and/or comorbid conditions. Secondary conditions are directly related to a primary condition. In the case of cardiopulmonary conditions, examples of secondary conditions could include delirium, pneumonia, stasis ulcers, and pressure ulcers. Comorbid conditions affecting beneficiaries with cardiopulmonary conditions are, by definition, distinct from the primary condition itself. 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. 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. 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. 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, and depth of respiration. 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. 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 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 and restriction in participation related to the comorbid condition. 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 (e.g., aortic stenosis, chronic obstructive pulmonary disease, or 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 6 months or less.

The documentation of structural/functional impairments and activity limitations facilitate the selection of the most appropriate intervention strategies (palliative/hospice versus long-term disease management), and provide 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

N/A

Analysis of Evidence (Rationale for Determination)

N/A

Proposed Process Information

Synopsis of Changes

Changes	Fields Changed
	N/A

Associated Information

Sources of Information

Bibliography

Open Meetings

Contractor Advisory Committee (CAC) Meetings

MAC Meeting Information URLs

Proposed LCD Posting Date

Comment Period Start Date

Comment Period End Date

Reason for Proposed LCD

Requestor Name	Requestor Letter
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Requestor Information

Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code	Description
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Revenue Codes

Code	Description
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ICD-10-CM Codes that Support Medical Necessity

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

Additional ICD-10 Information

General Information

Associated Information

Documentation Requirements

Documentation certifying terminal status must contain enough information to confirm terminal status upon review. Documentation meeting the criteria listed under the Coverage Indications, Limitations and/or Medical Necessity section of this policy would contribute to this requirement. 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 HHH MAC upon request.

Sources of Information

N/A

Bibliography

Carabello BA. Clinical practice: Aortic stenosis. N Engl J Med. 2002;346(9):677-682.

Del Fabbro E, Dalal S, Bruera E. Symptom control in palliative care-part III: Dyspnea and delirium. J Palliat Med. 2006;9(2):422-436.

Rich MW. Heart failure in older adults. Med Clin North Am. 2006;90(5):863-885.

Stuart B. Palliative care and hospice in advanced heart failure. J Palliat Med. 2007;10(1):210-228.

Revision History Information

Revision History Date	Revision History Number	Revision History Explanation	Reasons for Change
03/21/2024	R13	Under *Coverage Indications, Limitations and/or Medical Necessity* removed verbiage from second and third paragraph related to the International Classification of Functioning, Disability and Health (ICF) as it is no longer accessible. Under *Bibliography* removed the third reference as it is no longer accessible.	Provider Education/Guidance
12/14/2023	R12	Under *CMS National Coverage Policy* section headings were updated for regulations. The following regulation was removed: “Federal Register, Volume 70, No. 224, dated Tuesday, November 22, 2005, page 70537” as this is covered in “42 CFR, Part 418 Hospice Care” listed in this section. Under *Bibliography* changes were made to citations to reflect AMA citation guidelines. Formatting and punctuation errors were corrected throughout the LCD.	Provider Education/Guidance
11/04/2021	R11	Under *CMS National Coverage Policy* updated regulation descriptions and section headings. Punctuation was corrected throughout the LCD.	Provider Education/Guidance
06/11/2020	R10	Under *CMS National Coverage Policy,* Title XVIII of the Social Security Act, §1814(i) addressing payment for hospice care, was moved to the related Billing and Coding: Hospice Cardiopulmonary Conditions A56610 article. Regulations unrelated to billing and coding were removed from related Billing and Coding: Hospice Cardiopulmonary Conditions A56610 article and moved to the *CMS National* *Coverage Policy* section of this LCD. Formatting, punctuation and typographical errors were corrected throughout the LCD. At this time 21^stCentury 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
10/10/2019	R9	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. Regulations regarding billing and coding were removed from the *CMS National Coverage Policy* section of this LCD and placed in the related Billing and Coding: Hospice Cardiopulmonary Conditions A56610 article. 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
06/06/2019	R8	All coding located in the *Coding Information* section has been moved into the related Going Beyond Diagnosis®: Hospice Cardiopulmonary Conditions A50422 article and removed from the LCD. Under *Bibliography* changes were made to citations to reflect AMA citation guidelines. Formatting, punctuation and typographical errors were corrected throughout the LCD. At this time 21^stCentury 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
05/24/2018	R7	Under *Associated Information* in the first sentence added the verbiage “Local Coverage Determination” in front of the acronym “LCD”. Under *Sources of Information*, revisions were made to reflect AMA citation guidelines. 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.	Risk Identified by a Zone Program Integrity Contractor (ZPIC)
01/01/2017	R6	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
06/03/2016	R5	Under *CMS National Coverage Policy* 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 *Coverage Indications, Limitations and/or Medical Necessity* added “and” before mental wellbeing to the first paragraph verbiage. Under *Associated Information- Documentation Requirements* bolded and italicized *Coverage Indications, Limitations and/or Medical Necessity*, added an “A” initial to author’s name and corrected punctuation.	Provider Education/Guidance Typographical Error
01/01/2016	R4	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	R3	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	R2	Under Coverage Indications, Limitations and/or Medical Necessity in the first paragraph, third sentence add “measures of functioning, physical illness, mental wellbeing, as well as,” to clarify health status, and changed the word “right” to appropriate in the last sentence. Under ICD-10 Codes that support Medical Necessity added the statement “While there are no specific ICD-10-CM codes for end stage cardiopulmonary conditions, the ICD-10-CM code describing the most relevant illness, disorder, or injury contributing to the prognosis of six months or less should be coded.” Under Associated Information corrected the sentence “….Indications and Limitations of Coverage….” To read “…Coverage Indications, Limitations and/or Medical Necessity…”. Under Sources of Information and Basis for Decision corrected all sources to AMA formatting.	Provider Education/Guidance Other (Annual Validation)
10/01/2015	R1	Under CMS National Coverage Policy added Hospice Care to 42 CFR Chapter IV, Part 41. Under Coverage Indications, Limitations and /or Medical Necessity removed “Health status mediates the much studied relationship between ICD-9-CM diagnosis and care outcomes.”	Other (Maintenance (Annual Review))

Associated Documents

Attachments
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Updated On	Effective Dates	Status
03/11/2024	03/21/2024 - N/A	Currently in Effect	You are here
12/08/2023	12/14/2023 - 03/20/2024	Superseded	View
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Keywords

Hospice
Cardiopulmonary Conditions

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Hospice Cardiopulmonary Conditions

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ICD-10-CM Codes that Support Medical Necessity

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