Phone Number
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Hospice
Qualification
Medicare
guidelines
Hospice
Qualification
Medicare
guidelines
Coverage Indications, Limitations, and Medical Necessity
Medicare coverage for hospice depends on a physician’s certification that an individual’s prognosis includes a life expectancy of six months or less if the terminal illness follows its normal course.
This Local Coverage Determination (LCD) outlines the guidelines used by National Government Services (NGS) to review hospice claims and assist hospice providers in determining beneficiary eligibility for hospice benefits. While this LCD includes guidelines specific to certain disease categories, it applies to all hospice patients. Its purpose is to identify Medicare beneficiaries whose current clinical status and anticipated disease progression make a life expectancy of six months or less more likely than not.
Clinical variables with general applicability, regardless of diagnosis, as well as those specific to certain conditions, are provided. Patients who meet these guidelines are expected to have a life expectancy of six months or less if their terminal illness follows its normal course. However, some patients may not meet these specific guidelines yet still have a life expectancy of six months or less. Coverage for such patients may be approved if documentation supports a prognosis of less than six months.
- guidlines
Section 322 of BIPA amended section 1814(a) of the Social Security Act by clarifying that the certification of an individual who elects hospice “shall be based on the physician’s or medical director’s clinical judgment regarding the normal course of the individual’s illness.” The amendment clarified that the certification is based on a clinical judgment regarding the usual course of a terminal illness, and recognizes the fact that making medical prognostications of life expectancy is not always exact.
- guidlines
However, the amendment regarding the physician’s clinical judgment does not negate the fact that there must be a basis for a certification. A hospice needs to be certain that the physician’s clinical judgment can be supported by clinical information and other documentation that provide a basis for the certification of 6 months or less if the illness runs its normal course.
- guidlines
If a patient improves and/or stabilizes sufficiently over time while in hospice such that he/she no longer has a prognosis of six months or less from the most recent recertification evaluation or definitive interim evaluation, that patient should be considered for discharge from the Medicare hospice benefit. Such patients can be re-enrolled for a new benefit period when a decline in their clinical status is such that their life expectancy is again six months or less.
start your
CARE JOURNEY
Are you looking for hospice care for your loved one? Do you feel overwhelmed and unsure of whereA to begin? Our knowledgeable and professional staff will answer any questions that you may have and help guide you on the next steps.
start your
CARE JOURNEY
Are you looking for hospice care for your loved one? Do you
feel overwhelmed and unsure of whereA to begin? Our knowledgeable
and professional staff will answer any questions that you may have
and help guide you on the next steps.