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Hospice Care Services Coverage Criteria
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Defines medical necessity, covered services, levels of care, eligibility, and exclusions for hospice care under Cigna-administered health benefit plans; applies to providers and members whose benefit plans include hospice coverage.
No material clinical or coverage changes in this revision.
Coverage Criteria for Hospice Services
Hospice medical necessity
Hospice care services are considered medically necessary when ALL of the following criteria are met:
supported by physician certification
policy allows concurrent palliative and some curative/life-prolonging treatments
Considered Medically Necessary (by code groups)
Considered Medically Necessary when criteria in the applicable policy statements listed above are met:
Codes are time-, location-, and service-specific and require supporting clinical documentation per the applicable policy statements (examples include 99497-99498, G0151-G0153, G0155-G0156, G0162, G0299-G0300, G0337, G0493-G0496, Q5001-Q5010, S0255, S0257, S9126, 0651-0659).
The policy identifies specific services that are not considered medically necessary or are outside the scope of hospice coverage. These include services provided to an individual who is no longer considered terminally ill, interventions that are provided primarily to assist with activities of daily living (ADLs) such as personal hygiene, feeding, dressing, or transfers, and items intended for general nutritional support (including nutritional supplements, vitamins, and minerals) or non‑prescription drugs. Also excluded are medical supplies unrelated to the palliative care being provided and any services for which benefits are available under another coverage category. Claims for such items or services should not be submitted as hospice care because they do not meet the policy’s definition of medically necessary hospice services.
Respite care provided specifically for hospice and billed with HCPCS code S9125 (respite care, in the home, per diem) is explicitly excluded and not covered by this policy when the respite is specific to hospice. Providers should not bill S9125 for hospice‑specific respite services under Cigna‑administered plans.
Services that are primarily intended to support activities of daily living (ADLs) rather than to provide palliative medical care are considered not medically necessary as hospice services. Examples include help with bathing, feeding, dressing, toileting, or transfers. In addition, non‑prescription items and supplies used for general support—such as over‑the‑counter drugs, vitamins, minerals, and nutritional supplements—or medical supplies that are not directly related to the palliative plan of care are not considered hospice‑covered items and are not medically necessary under this policy.
Code Listings and Clinical Thresholds
| 99497 | Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate. |
| 99498 | Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; each additional 30 minutes (List separately in addition to code for primary procedure). |
| G0151 | Services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes. |
| G0152 | Services performed by a qualified occupational therapist in the home health or hospice setting, each 15 minutes. |
| G0153 | Services performed by a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes. |
| 99497 | Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate. |
| 99498 | Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; each additional 30 minutes (List separately in addition to code for primary procedure). |
| G0151 | Services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes. |
| G0152 | Services performed by a qualified occupational therapist in the home health or hospice setting, each 15 minutes. |
| G0153 | Services performed by a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes. |
| G0155 | Services of clinical social worker in home health or hospice setting, each 15 minutes. |
| G0156 | Services of home health/hospice aide in home health or hospice settings, each 15 minutes. |
| G0162 | Skilled services by a registered nurse (RN) for management and evaluation of the plan of care; each 15 minutes (the patient's underlying condition or complication requires an RN to ensure that essential non-skilled care achieve its purpose in the home health or hospice setting). |
| G0299 | Direct skilled nursing services of a registered nurse (RN) in the home health or hospice setting, each 15 minutes. |
| G0300 | Direct skilled nursing services of a licensed practical nurse (LPN) in the home health or hospice setting, each 15 minutes. |
| G0337 | Hospice evaluation and counseling services, pre-election. |
| G0493 | Skilled services of a registered nurse (RN) for the observation and assessment of the patient's condition, each 15 minutes (the change in the patient's condition requires skilled nursing personnel to identify and evaluate the patient's need for possible modification of treatment in the home health or hospice setting). |
| G0494 | Skilled services of a licensed practical nurse (LPN) for the observation and assessment of the patient's condition, each 15 minutes (the change in the patient's condition requires skilled nursing personnel to identify and evaluate the patient's need for possible modification of treatment in the home health or hospice setting). |
| G0495 | Skilled services of a registered nurse (RN), in the training and/or education of a patient or family member, in the home health or hospice setting, each 15 minutes. |
| G0496 | Skilled services of a licensed practical nurse (LPN), in the training and/or education of a patient or family member, in the home health or hospice setting, each 15 minutes. |
| Q5001 | Hospice or home health care provided in patient's home/residence. |
| Q5002 | Hospice or home health care provided in assisted living facility. |
| Q5003 | Hospice care provided in nursing long-term care facility (LTC) or nonskilled nursing facility (NF). |
| Q5004 | Hospice care provided in skilled nursing facility (SNF). |
| Q5005 | Hospice care provided in inpatient hospital. |
| Q5006 | Hospice care provided in inpatient hospice facility. |
| Q5007 | Hospice care provided in long-term care facility. |
| Q5008 | Hospice care provided in inpatient psychiatric facility. |
| Q5009 | Hospice or home health care provided in place not otherwise specified (NOS). |
| Q5010 | Hospice home care provided in a hospice facility. |
| S9125 | Respite care, in the home, per diem |
Provider Requirements and Authorization
Prior Authorization / Code applicability
Prior authorization and code applicability: Hospice services are subject to the terms, conditions, and limitations of the member's benefit plan. When hospice benefits are available, providers must follow plan requirements and submit services using the appropriate covered diagnosis and procedure codes. Claims submitted without covered diagnosis or procedure codes listed in this policy will be denied. Prior authorization (utilization review) may be required per the member's plan — verify benefit availability and any authorization requirements with the applicable benefit plan document and payer before rendering services.
- Claims must include covered diagnosis/procedure codes listed in this policy.
- Verify prior authorization requirements and benefit availability with the member's plan document.
- When billing, use the most appropriate codes as of the date of service.
Authorization tied to listed codes
Services coded with the CPT, HCPCS and Q5000-series codes listed in this policy are considered medically necessary when the hospice eligibility and clinical criteria in this policy are met. Bill only for services and sites of care that match the member's clinical needs and the hospice level of care.
Required documentation for eligibility
Providers must document hospice eligibility and physician certification in the medical record. Documentation should support the physician's clinical judgment that the patient is terminally ill with a life expectancy of 12 months or less (if the disease follows its expected course) and include evidence such as disease progression, functional status (e.g., Karnofsky ≤50%), weight loss, nutritional and mental status assessments, and focused physical exam findings. If the member survives beyond 12 months, the physician must recertify terminal status to continue hospice benefits.
- Document history of recent disease progression, treatments, and indications of severity.
- Record functional status (Karnofsky score, ADL dependence) and relevant nutritional or laboratory indicators.
- Physician certification and recertification must be in the medical record to support continued coverage.
Required coding documentation
Maintain documentation linking billed CPT/HCPCS/QC codes to the medical record and hospice plan of care. Claims for hospice services must include the appropriate place-of-service and setting-specific Q5000-series or revenue codes as applicable. Failure to submit required documentation or to use covered codes may result in claim denial or delay.
- Include Q5001–Q5010 or appropriate revenue codes (0651, 0652, 0657–0659) to reflect site of care.
- Support billed CPT/HCPCS codes (e.g., G0151–G0153, G0155–G0156, G0162, G0299–G0300) with clinical notes and time-based records.
- Claims lacking covered diagnosis or procedure codes listed in this policy will be denied.
Coding-related denial risk
Claims without a covered diagnosis or procedure code listed in this policy will be denied. Verify that the service and diagnosis codes on the claim align with the member's benefit plan and the hospice medical record before submission.
- Denial risk applies when billed codes are not among those listed as covered or medically necessary for hospice services.
- Ensure diagnosis supports hospice eligibility and is documented in the medical record.
Respite care exclusion
Respite care provided under a hospice benefit has specific coding exclusions: S9125 (Respite care, in the home, per diem) is excluded and not covered when respite care is specific to hospice. Use applicable covered hospice respite codes or revenue codes if the plan allows respite under hospice; otherwise, do not bill S9125 for hospice respite.
Definitions and Program Terms
Background
This policy describes hospice as a palliative approach focused on comfort and symptom management rather than cure, delivered to individuals who are terminally ill and appropriate for hospice services. Hospice care is interdisciplinary and addresses physical, psychological, social, and spiritual needs; it may be provided in the home or in inpatient settings. The policy’s exclusions emphasize that hospice benefits are limited to services that support palliative care goals and do not extend to routine ADL assistance, nutritional supplements, non‑prescription items, or supplies unrelated to symptom management.
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