Local Coverage Determination (LCD)

Hospice - Neurological Conditions

L34547

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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
L34547

LCD Title
Hospice - Neurological 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 11/14/2024

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, §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 under paragraph (1)(C)).

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 under paragraph (1)(C)).

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 under subsection (d)(1).

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 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

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, §20.2.1.1 Hospice Election Statement, §40 Benefit Coverage, §40.1 Covered Services, §40.1.1 Nursing Care, §40.1.2 Medical Social Services, §40.1.3 Physicians' Services, §40.1.3.1 Attending Physician Services, §40.1.3.2 Nurse Practitioners as Attending Physicians, §40.1.4 Counseling Services, §40.1.5 Short-Term Inpatient Care, §40.1.6 Medical Appliances and Supplies, §40.1.7 Hospice Aide and Homemaker Services, §40.1.8 Physical Therapy, Occupational Therapy, and Speech-Language Pathology, §40.1.9 Other Items and Services, §40.2.1 Continuous Home Care (CHC), §40.2.2 Respite Care, §40.2.3 Bereavement Counseling, §40.2.4 Special Modalities, §40.3 Contracting With Physicians, §40.4 Core Services, §40.4.1 Contracting for Core Services, §40.4.1.1 Contracting for Highly Specialized Nursing Services, §40.4.2 Waiver for Certain Core Staffing Requirements, §40.4.2.1 Waiver for Certain Core Nursing Services, §40.5 Non-core Services and §80 Hospice Pre-Election Evaluation and Counseling Services

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Neurological 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 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 neurological conditions and thus promote the overall goal of the right care for every person, every time.

Neurological 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 neurological conditions, examples of secondary conditions could include dysphagia, pneumonia, and pressure ulcers. Comorbid conditions affecting beneficiaries with neurological conditions are, by definition, distinct from the primary condition itself, however, services aimed at the comorbid condition may indeed be related to the palliation and/or management of the terminal condition. An example of a comorbid condition would be chronic obstructive pulmonary disease (COPD).

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:

Neurological 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 neurological conditions results from the presence of impairments in such body functions as consciousness, attention, sequencing complex movements, ingestion (which includes chewing, manipulation of food in the mouth, and swallowing), muscle power, tone, and endurance. These impairments contribute to the increased incidence of secondary conditions such as dysphagia, pneumonia, and pressure ulcers observed in Medicare beneficiaries with neurological conditions. Secondary conditions themselves may be associated with a new set of structural/functional impairments that may or may not respond or be amenable to treatment.

Ultimately, in order to support a hospice plan of care, the combined effects of the primary neurological 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 neurological condition such as amyotrophic lateral sclerosis (ALS) and a comorbidity of COPD could have specific COPD-related structural and functional impairments of respiration (e.g., structural impairments of the bronchoalveolar tree resulting in increased respiratory rate, cough and impaired gas exchange) that contribute to the activity limitations and participation restrictions already present due to the respiratory muscle weakness often observed with ALS.

Such a combination could affect the palliative care plan by contributing to the individual’s dyspnea and impaired exercise tolerance. Palliative care aimed at relieving the dyspnea and improving the individual’s health status would be the goal.

Ultimately, in order to support a hospice plan of care, the combined effects of the primary neurologic 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, together with the observed activity limitations, facilitate the selection of the most appropriate intervention strategies (palliative/hospice vs. 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

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Requestor Information

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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

1. Documentation supporting medical necessity should be legible, maintained in the patient’s medical record, and must be made available to the A/B HHH MAC upon request.

2. 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.

3. If the patient does not meet the criteria outlined under Coverage Indications, Limitations and/or Medical Necessity section of this policy, yet is deemed appropriate for hospice care, sufficient documentation of the patient's condition that justifies terminal status, in the absence of meeting the above criteria, would be necessary.

4. Recertification for hospice care requires that the same standards be met as for the initial certification.

Sources of Information

N/A

Bibliography

1. Espinoza S, Walston JD. Frailty in older adults: Insights and interventions. Cleve Clin J Med. 2005;72(12):1105-1112.

Revision History Information

Revision History Date	Revision History Number	Revision History Explanation	Reasons for Change
11/14/2024	R11	Under *Coverage Indications, Limitations and/or Medical Necessity* removed verbiage in second, third and ninth paragraphs related to the International Classification of Functioning, Disability and Health (ICF) as it is no longer utilized. Under *Bibliography* deleted the third, fourth and fifth references as they are no longer utilized. Formatting and punctuation errors were corrected throughout.	Provider Education/Guidance
11/30/2023	R10	Under *CMS National Coverage Policy* section headings were updated for regulations. The following regulation was removed and placed in the related Billing and Coding: Hospice - Neurological Conditions A56502 article: “Title XVIII of the Social Security Act, §1813 (a)(4)(A)(i) drugs and biologicals provided in a hospice program”. Under *Bibliography* changes were made to citations to reflect AMA citation guidelines. Formatting and punctuation errors were corrected throughout the LCD.	Provider Education/Guidance
10/24/2019	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. 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 – Neurological Conditions A56502 article. 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
04/18/2019	R8	All coding located in the *Coding Information* section has been moved into the related Billing and Coding: Hospice – Neurological Condition A56502 article and removed from the LCD. Under *Coverage Indications, Limitations and/or Medical Necessity* removed italicized text from all verbiage. 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*, second “Documentation Requirement” added the verbiage “Local Coverage Determination” in front of the “LCD” acronym. 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 Public Education/Guidance
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
06/30/2016	R5	Under *CMS National Coverage Policy* added the verbiage “the term "hospice care" means the services provided to a hospice patient” to Title XVIII of the Social Security Act, §1861 (dd)(1). Title XVIII of the Social Security Act, §1862 (a)(1)(A) was separated and the verbiage “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” was added. Title XVIII of the Social Security Act, §1862 (a)(6) was separated and the verbiage “ items and services which constitute personal comfort items (except, in the case of hospice care, as is otherwise permitted under paragraph (1)(C))” was added. Title XVIII of the Social Security Act, §1862 (a)(9) was separated and the verbiage “ items and services where such expenses are for custodial care (except in the case of hospice care, as is otherwise permitted under paragraph (1)(C))” was added. The verbiage “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 under subsection (d)(1)” was added to the Title XVIII of the Social Security Act, §1812 (a)(4) and (d)(1). The verbiage “drugs and biologicals provided in a hospice program” was added to the Title XVIII of the Social Security Act, §1813 (a)(4)(A)(i). The verbiage “certifying the patient for hospice” was added to the Title XVIII of the Social Security Act, §1814 (a)(7)(A)(i). The title “Medicare General Information, Eligibility, and Entitlement” was added to CMS Internet-Only Manual Pub 100-01, Chapter 1, §10.1. The title “Medicare General Information, Eligibility, and Entitlement” was added to CMS Internet-Only Manual Pub 100-01, Chapter 4, §60. The title “Medicare Benefit Policy Manual” was added to CMS Internet-Only Manual, Pub 100-02, Chapter 9 and sections 20.2 and 40.2 were removed. Change Request 9369 was deleted as the information has been manualized and the following reference was added: CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 11, §§30.2, 30.2.2, and 30.3. Under *Sources of Information and Basis for Decision* added an initial to an author’s name and corrected the order of a reference.	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	Under CMS National Coverage Policy added reference to Pub. 100-02 Chapter 9 for 20.2.1.1, 40.1, 40.1.1, 40.1.2, 40.1.3, 40.1.3.1, 40.1.3.2, 40.1.4, 40.1.5, 40.1.6, 40.1.7, 40.1.8, 40.1.9, 40.2, 40.2.1, 40.2.2, 40.2.3, 40.2.4, 40.3, 40.4, 40.4.1,40.4.1.1, 40.4.2, 40.4.2.1, & 40.5. Under Coverage Indications, Limitations, and /or Medical Necessity made a few grammatical and punctuation corrections. Under ICD-10 Codes that Support Medical Necessity added the paragraph “While there are no specific ICD-10-CM codes for neurological 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 made corrections to spacing and punctuation. Under Sources of Information and Basis for Decision corrected all sources to AMA formatting and added citation for Espinoza and Walston’s article “Frailty in older adults: insights and interventions”.	Provider Education/Guidance Typographical Error Other (Annual Validation)
10/01/2015	R2	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 revenue code removal)
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.” In the 42 CFR, removed “and the conditions that a hospice program must meet in order to participate in the Medicare program.” Removed “Medicare General Information, Eligibility, and Entitlement Manual.” Under Coverage Indications, Limitations and/or Medical Necessity removed “Health status mediates the much studied relationship between ICD-9-CM diagnosis and care outcomes.” Made grammatical and punctuation corrections throughout policy.	Provider Education/Guidance Other (Maintenance- Annual Validation)

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Updated On	Effective Dates	Status
11/06/2024	11/14/2024 - N/A	Currently in Effect	You are here
11/20/2023	11/30/2023 - 11/13/2024	Superseded	View
10/14/2019	10/24/2019 - 11/29/2023	Superseded	View
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Keywords

Hospice
Neurological Conditions

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Hospice - Neurological Conditions

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CPT/HCPCS Codes

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ICD-10-CM Codes that Support Medical Necessity

Group 1

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

Group 1

Additional ICD-10 Information

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Keywords

Page Help for LCD - Hospice - Neurological Conditions (L34547)

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