Simione™ Healthcare Consultants

Hospice Series Part 4: Hospice Compliance Checklist for 2014

Caring for terminally ill people is the mission of hospices. Unfortunately, the resources now being spent within hospice agencies are often focused more on compliance than on patient care. With so many reasons for this evolution over the past 30 years, the finger cannot be pointed at one single cause or entity. Regardless, hospice programs of all sizes must understand the need for robust compliance programs which work in unison with their education and quality departments in order to be ready for the next CMS probe. This can certainly be a significant challenge particularly for smaller providers who may have limited resources, but a necessary one, as it is not a matter of 'if' but a matter of 'when' CMS will shine the light on your hospice.

As the fourth in our Hospice Series articles, we are summarizing the first three into a bulleted list of what should be on your compliance checklist for the 2014. While some of these are areas you have been monitoring for years, they remain just as important. Many of the items can be assessed, reviewed and/or monitored with the use of a single tool while auditing records; many of the items should be on your dashboard and easily accessible through electronic reports. Some of these items may need to become part of the IDG meeting or another meeting/setting.

Hospice Patients: How many, what percentage?

  • Long lengths of stay (>180 days)

  • Live dischargesNon-cancer diagnosis

  • Nursing home patients

    • What process is used to review the above records and ensure eligibility and excellence in documentation?


  • Debility and AFTT should no longer be primary terminal diagnosis (effective October 1, 2014 these will be Returned To Provider)

  • Appropriate Dementia diagnosis codes are used in accordance with ICD-9 CM coding guidelines and sequencing

  • The hospice MD and IDG must have determined the most appropriate primary terminal diagnosis.

    • All co-morbid, secondary and related diagnoses are listed after the terminal diagnosis

    • The terminal and all related diagnoses are properly listed on the billing claim

    • Any unrelated disease:

      • Is not listed on the claim form

      • Is documented by the hospice MD in the clinical record as to why it is unrelated


  • All medications the patient is taking are listed on the med list

    • Each medication has an indication of 'covered by hospice' or 'non-covered' after careful review by RN and MD to determine the relationship to disease and possible palliative effects

      • Those medications deemed 'non-covered' are documented by MD as to why they are unrelated

      • Lists of medications with above information is reviewed and updated with caregivers, pharmacy and nursing home along with education to same to not bill Medicare Part D for covered medications

  • Monthly claims reviewed to ensure that only medications provided to the patient that are related to the terminal illness are included on the Medicare claim

  • Non-formulary medications (if a hospice uses a formulary) that are deemed necessary for palliation and/or management of the terminal illness and related conditions are covered by the hospice

Plan of Care

  • Reflects and is current with updates to include all services needed for the palliation and management of the terminal illness and related conditions

    • Including medications

Additional reporting requirements; Voluntary from January 6, 2014; Mandatory effective April 1, 2014

  • GIP in SNFs or Hospitals (hospice IPUs not effected)

    • All hospice staff (Nurse, SW, PT, OT, ST, Aide) visits are reported on claim as line items in 15 minute increments

  • NPI numbers

    • NPI of facility or hospital or hospice facility where patient is receiving care is listed on the claim, regardless of level of care

      • When services are received at more than one facility in a month, the latest one is listed

  • Post Mortem Visits

    • All visits after the time of death, on the same calendar day, are billed with a PM modifier

      • Visits on dates after date of death are not reported on claim

  • Prescription Drugs

    • Injectable drugs are reported as line items using revenue code 0636 and the applicable HCPCS code

    • Non-injectables are reported using revenue code 0250 and the applicable National Drug Code (NDC)

    • Non-prescription (OTC) medications are not reported on the claim

  • Infusion Pumps

    • Infusion pumps are reported using revenue code 029X and the applicable HCPCS code

    • Each infusion medication refill is reported with revenue code 0284 and the applicable HCPCS

The areas noted in this summary article were discussed in greater depth in the three previous Simione Hospice Series articles which can be referenced below.

Share This