COVID-19 Complicates Hospice Compliance With New CMS Addendum Rule

Providers have been strained to comply with the new Medicare requirement for an addendum to the hospice election statement. Gusty pandemic-related headwinds and documentation errors are among the obstacles that hospices are encountering as 2020 comes to a close.

The addendum rule that took effect Oct. 1, 2020, requires hospices to provide Medicare beneficiaries with a written statement called a “Patient Notification of Hospice Non-Covered Items, Services, and Drugs” detailing the conditions, items, services or drugs that are determined to be unrelated to their terminal illness and conditions and not covered by the hospice benefit.

The COVID-19 pandemic has further complicated providers’ efforts to comply, according to Carrie Cooley, principal, CEO and co-owner of the consulting firm Weatherbee Resources.


“COVID-19 has impacted everything we do personally and professionally,” said Cooley in a Hospice News webinar. “The biggest challenge that we’ve seen since implementation of the new election statement, and since March, is there was not a regulatory allowance to accommodate the election process with COVID.”

Patients admitted on or before the effective addendum date have the option to request the notice upon electing the Medicare Hospice Benefit. When the patient or their representative requests the addendum on the day of admission, hospices have five days after the date of election to prepare the addendum and deliver it. If the addendum is requested at any point after the date of admission, the hospice must issue the written addendum within three days, or 72 hours.

Hospices must also issue an updated addendum to patients or their representatives, regardless of request, when there are changes in what is considered to be unrelated to their course of care.


The need for social distancing during the COVID-19 pandemic has created a roadblock for hospices. The addendum rule requires them to obtain a physical patient or surrogate decision-maker signature at the time of hospice election or admission.

Despite regulatory waivers expanding the use of telehealth services during the COVID-19 pandemic, hospice providers have been hard-pressed to reach many patients in facility- or community-based settings.

“Some waivers were issued where we could provide visits remotely, but for [hospice] election, it still requires a physical signature,” Cooley told Hospice News. “There’s never been a regulatory allowance for verbal election of hospice, and that did not change with COVID, and the reason for these regulatory changes is that [the U.S. Centers for Medicare & Medicaid Services (CMS)] wants to make sure that the patient and the family really understand what they are electing.”

Another wave of pandemic is sweeping the country, with the U.S. Centers for Disease Control and Prevention (CDC) reporting more than 588,000 new cases and 510 deaths in the last week alone, citing the rise as an indicator of up to 240,000 additional COVID-19 cases before the end of November.

Responding to the pandemic has slowed hospice operations and billing processes, creating a perfect storm of documentation challenges and posing threats of additional financial dips. Hospice providers struggled with documenting for relatedness, risking payment denial if documents are deficient or not submitted within required time frames.

According to Cooley, hospices can overcome compliance with issues related to the new addendum to the election statement by improving efficiency of their electronic filing processes and expanding documentation training beyond clinical care teams into other hospice operational areas such as billing and accounting.

“The [CMS] final rule stated the election statement and the addendum are conditions for payment,” Cooley said. “That means if these documents are deficient, if they’re untimely or if they are absent, then the hospice is not entitled to payment. For all patients admitted on or after Oct. 1, the election statement language changed. Medicare does require that we use a specific form, but they were very clear on the language that had to be included in the [hospice] election.”

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