Hospices Adjust to New CMS Addendum Rule

Hospices have shifted staff training as well as patient admission and documentation processes amid a barrage of changes since the U.S. Centers for Medicare & Medicaid Services (CMS) issued the election statement addendum rule Oct. 2020. While the new rule could stand to improve patient awareness and understanding of hospice, providers who fail to comply face financial risks.

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,” describing the conditions, items, services or drugs that are determined to be unrelated to their terminal illness and not covered by the hospice benefit.

Operational implementation has been among the most significant obstacles for providers to hurtle past in the last five months, with added weight from the COVID-19 outbreak complicating many hospices’ efforts to comply. New patient admission and clinical documentation processes have placed additional strain on hospice staff as the pandemic continues to exacerbate industry-wide workforce shortages and cause unprecedented levels of burnout, fatigue and trauma in the workplace.


Providers have needed to revamp staff education and training, along with keeping teams abreast on shifts in patient documentation strategies pertaining to the new rule.

“Many hospices have reported that the greatest challenge was getting the process set up and making sure staff had the resources they needed to talk with patients and their representatives,” Judi Lund Person, vice president of regulatory and compliance for National Hospice and Palliative Care Organization (NHPCO), told Hospice News. “The onus is on the hospice to document why the hospice team, the hospice medical director, the hospice physician in consultation with the team feel that a particular medication is not related to the terminal illness and related conditions.”

With the addendum in place, documentation will be a key part of the medical review process for patients who have been admitted since the Oct. 1 effective date, as Lund Person stated during a recent NHPCO webinar.


Patients have the option to request the notice upon electing the Medicare Hospice Benefit. If patients or families make the request 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.

Many hospices have scrambled to make the necessary modifications to their existing hospice election statements and develop the addendum statement while also establishing processes that incorporate these changes into their workflow, according to a Govregs report.

Hospices often face challenges when it comes to documenting which services are directly related to a patient’s terminal diagnosis as opposed to a comorbidity.

“The addendum, that’s the first look, but relatedness and coverage determination are something that is patient-centered and reassessed throughout the course of that patient’s trajectory of illness and their care with you,” said Bernice Burkharth, M.D., chief medical officer of the Home Health Foundation, during the NHPCO webinar. “Staff education is the first step, understanding the process so that they can understand better what the purpose is, and then having greater ease and having conversations around the [addendum] request.”

Including a close examination of patients’ health histories and maintaining detailed and accurate records of their care plans and medications are important pieces for hospices to incorporate into their documentation processes. Ongoing reevaluation of documentation processes and staff training will be large considerations for providers.

Technological investment in electronic systems to incorporate the addendum changes, along with additional staffing hours dedicated to this process have created trickle-down costs for hospices already being pummeled by pandemic-related headwinds.

A limited time window to respond to patients, families or representatives requesting the addendum also weighs heavily on hospices. When the patient or their representative requests the addendum on the day of admission, hospices have a five-day window after the date of election to prepare the addendum and deliver it.

“A hospice must remain vigilant to ensure that the addendum is provided to the patient and their representative within the five-day window,” Lund Person told Hospice News. “If that time frame is not met, the hospice does run the risk of the claim being denied. However, the denial is limited to only the claim subject to review and would not invalidate the entire election.”

Despite the risks, the addendum may pose rewards for hospice providers by expanding the opportunity to build relationships with patients and their families. The process can also help improve awareness and understanding of hospice and palliative care through ongoing discussions with staff and clinical care teams. Public perception and a general lack of understanding of these services have been leading causes behind reluctance to accept and pursue hospice care, according to a study in the Journal of Palliative Medicine.

Particularly beneficial may be deeper conversations about deprescribing the patient’s medications.

“The barrier that we may hit is having those conversations with the patient and the caregiver, and convincing them that starting the process of deprescribing certain medications will be of benefit to them. You need to build a foundation of trust and respect,” said Marisa Todd, clinical pharmacy lead at Enclara Pharmacia, during the webinar. “Building that foundation, that’s not going to happen on admission to a hospice or palliative care program. You want to understand what the patient and the caregiver know about the topic to make the process go a lot smoother.”

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