Review of Hospital Admissions of Patients Who Have Elected

100.5 - Review of Hospital Admissions of Patients Who Have Elected Hospice Care (Rev. 1, 10-01-03) HO-418 Review of admissions to inpatient general hospitals of beneficiaries who have elected hospice care assures that: • Nonhospice Medicare coverage is provided to those beneficiaries only when the hospitalization was for a condition not related to the terminal illness, and • When inpatient hospital services were provided as a hospice benefit, the services rendered were stipulated in the individual's plan of care as established by the hospice's interdisciplinary group. A. - Review for Nonrelated Hospital Admissions To assure that nonhospice Medicare coverage is provided to beneficiaries who have elected hospice care only when hospitalization was for a condition not related to the terminal illness, the medical review agent reviews all inpatient hospital claims for these beneficiaries. Appropriate medical records will be requested and a determination made as to whether or not services were related to the individual's terminal illness. Many illnesses may occur when an individual is terminally ill which are brought on by the patient's underlying condition. For example, it is not unusual for a terminally ill patient to develop pneumonia or some other illness as a result of a weakened condition. Similarly, the setting of bones after fractures which occur in a bone cancer patient would be treatment of a related condition. If the review reveals hospitalization to be unrelated to the individual's terminal illness, a determination as to the medical necessity and appropriateness of the admission is made. Payment will be totally denied or totally approved based on the finding. If, after review, the admission should have been totally denied, consideration under the limitation of liability provision (§1879 of the Act) applies. If the review of medical records reveals hospitalization to be related to the individual's terminal illness, the claim is denied as services waived through the hospice election. Limitation on liability provision does not apply. B. - Review for Related Hospital Admissions To assure that beneficiaries who have elected hospice care are receiving services as provided in the plans of care established by the hospice's interdisciplinary groups, the medical review agent reviews all inpatient hospital claims submitted by the hospice for these beneficiaries. Appropriate medical records (including the plans of care) are requested and a determination made as to whether or not services provided were related to the individual's terminal illness and stipulated in the plan of care. If the review reveals that services provided were medically necessary and appropriate for the control of pain or acute or chronic symptom management as outlined in the individual's plan of care, the claim is approved. If the review reveals that services provided to the hospice beneficiary were not stipulated in the plan of care as established by the hospice's interdisciplinary group, the claim is denied. Limitation on liability does not apply.