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Hospice Coverage Determination for Cancer

The Medicare Administrative Contractors (MACs) Cigna Government Services (CGS) and National Government Services (NGS) have set hospice eligibility criteria for patients with cancer as their terminal diagnosis that include assessing the non-disease-specific criteria alongside the disease-specific criteria.

As with all diagnoses for hospice patients, ultimately the eligibility is determined by the physician’s narrative statement in the Certification of Terminal Illness (CTI) of the specific reasons (including these LCD criteria) the patient has a prognosis of six months or less if the disease runs its expected course. Palmetto has not set disease-specific criteria for cancer, but as with all diagnoses without disease-specific criteria, agencies are expected to document in the hospice software the non-disease-specific criteria to show eligibility for hospice.

How to Determine Cancer Eligibility

Both NGS and CGS define cancer eligibility as either the disease has metastases at initial presentation of the disease or the disease has progressed to metastatic cancer, with either the patient showing a continued decline despite therapy or the patient declining future disease-directed therapy. NGS and CGS also acknowledge that with certain cancers that have poor prognosis at the onset (i.e., small cell lung cancer, brain cancer and pancreatic cancer) the patient may be hospice-eligible without other criteria being present.

Other Factors That Help Eligibility

Upon admission to hospice, obtaining records of treatments that have been administered to the patient – surgery, chemotherapy, radiation therapy, and clinical trials – as well as the presence of PET scans, MRIs, and CT scan results will bolster eligibility documentation in the CTI. These are especially useful, as patients can have improved functional status and symptom burden once they cease active cancer treatment. They also could have increased longevity after the side effects of cancer treatment have stopped causing decreased immune and nutritional status.

All MACs expect the hospice to determine the diagnoses related to the patient’s terminal prognosis and address all in the CTI narrative to accurately illustrate the reasons the physician believes the patient has a prognosis of six months or less. Furthermore, accurately identifying and assessing the patient’s full diagnoses will assist agencies with developing the most accurate and proactive plan of care for addressing the patient’s needs at the present time and during the hospice admission.

Documenting hospice eligibility in the hospice software for patients with cancer is more straightforward than other disease processes. Obtaining a thorough cancer treatment history, including diagnostic testing, will bolster the eligibility claims if the patient has a longer length of stay than anticipated after stopping cancer treatments. Axxess offers a library of useful blogs to help your hospice agency provide exceptional care.


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