#hospice medicare benefit
Discharge from Hospice Services
The hospice benefit is available only to individuals who are terminally ill; therefore, a hospice may discharge a patient if it discovers that the patient is not terminally ill. Discharge may also be necessary when the patient moves out of the service area of the hospice. The hospice notifies the Medicare contractor of the discharge so that hospice services and billings are terminated as of that date. In this situation, the patient loses the remaining days in the benefit period. However, there is no increase in cost to the beneficiary. General coverage under Medicare is reinstated at the time the patient revokes the benefit or is discharged.
Reasons for hospice discharge:
- The beneficiary decides to revoke the hospice benefit
- The beneficiary dies
- The patient moves out of the hospice’s service area or transfers to another hospice;
- The hospice determines that the patient is no longer terminally ill
- Discharge for cause: The hospice discharges the patient under a policy set by the hospice for the purpose of addressing discharge for cause, citing that the patient’s (or other persons in the patient’s home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the hospice to operate effectively is seriously impaired. The hospice must do the following before it seeks to discharge a patient for cause:
- Advise the patient that a discharge for cause is being considered;
- Make a serious effort to resolve the problem(s) presented by the patient’s behavior or situation;
- Ascertain that the patient’s proposed discharge is not due to the patient’s use of necessary hospice services; and
- Document the problem(s) and efforts made to resolve the problem(s) and enter this documentation into its medical records.
The hospice must make every effort to resolve these problems satisfactorily before it considers discharge an option. All efforts by the hospice to resolve the problem(s) must be documented in detail in the patient’s clinical record and the hospice must notify the Medicare contractor and State Survey Agency of the circumstances surrounding the impending discharge.
Prior to discharging a patient for any reason listed in paragraph (a) of this section, the hospice must obtain a written physician’s discharge order from the hospice medical director. If a patient has an attending physician involved in his or her care, this physician should be consulted before discharge and his or her review and decision included in the discharge note.
Effect of discharge
An individual, upon discharge from the hospice during a particular election period for reasons other than immediate transfer to another hospice—
- Is no longer covered under Medicare for hospice care;
- Resumes Medicare coverage of the benefits waived under § 418.24(d); and
- May at any time elect to receive hospice care if he or she is again eligible to receive the benefit.
- The hospice must have in place a discharge planning process that takes into account the prospect that a patient’s condition might stabilize or otherwise change such that the patient cannot continue to be certified as terminally ill.
- The discharge planning process must include planning for any necessary family counseling, patient education, or other services before the patient is discharged because he or she is no longer terminally ill.
§418.26 Discharge from hospice care
Out of Service Area Discharges
Effective July 1, 2012. CMS will require hospices to use new NUBC condition code 52 to indicate a discharge due to the patient’s unavailability/inability to receive hospice services from the hospice which has been responsible for the patient. In such a circumstance, the patient is considered to have moved out of the hospice’s service area. Examples of when such a code could be used include, but are not limited to, when a hospice patient moves to another part of the country or when a hospice patient leaves the area for a vacation. This code would also be appropriate when a hospice patient is receiving treatment for a condition unrelated to the terminal illness or related conditions in a facility with which the hospice does not have a contract, and thus is unable to provide hospice services to that patient. Medicare’s expectation is that the hospice provider would consider the amount of time the patient is in that facility before making a determination that discharging the patient from the hospice is appropriate.
The table below summarizes how hospice discharges would be coded on claims based on the changes in this CR and based on no changes to the coding for discharge for cause or for transfers: