Frequently asked questions about hospice. Please contact us if you have
additional questions.


We have a situation where our EMR is separating the arrival and time before a patient is pronounce and considering it an SIA visit. I feel that this is incorrect since upon arrival, we already know the patient had passed away. Sometimes it takes a nurse 10—15 minutes or more to get to patient to pronounce since families may be praying or someone is needing the nurse’s attention prior to entering the room. Does anyone know if this time is SIA billable? My EMR does, but we differ in opinion. We feel that if we received the call stating patient has passed away, that visit automatically is a post mortem visit.


As part of the introduction to the FY2016 final payment rule (which implemented the 2-tiered RHC payment system and the SIA) CMS commented:

Given that CMS intends to promote direct patient care in the 7 days prior to death, visits for the pronouncement of death will not be included as eligible visits for SIA payments.

Taken at face value, it does not sound as though CMS intends for that visit to be payable as an SIA visit.  We do recognize that there are instances where family members believe that a patient has died but hospice staff arrive and find that the patient is still alive but dies shortly thereafter, but this doesn’t sound like it is one of those cases.

The citation is located in the first column on page 47175 at:  https://www.gpo.gov/fdsys/pkg/FR-2015-08-06/pdf/2015-19033.pdf.


I realize that if a service is decreased from the original planned services ordered on the POC, a home health change of care notice is required for traditional Medicare beneficiaries.
My question is- would this still be required if the patient is requesting the nurse to come less frequent?  For instance, we front-loaded the frequency of a patient coming out of the hospital, and she is persistent that we only come once/week now.  If the verbal order includes that this is at the patient request, is a HHCN still required?

Would it be wiser to maintain frequency and write “missed visit” at patient request?  Just don’t want to raise flags with missed visits.



Document clearly the circumstances and your notification to the physician. Request new orders that show how you’ll address this patient’s medically necessary care given this change.
Be sure that you don’t negate your original frequency’s medical necessity due to the patient’s refusal. And be sure to document your explanation to the patient of why the original frequency was medically necessary, as well as potential consequences of refusing the care and your plans to attempt to compensate.
Because the reason for the HHCN is to document that the patient is informed of the change, the HHCN is not needed when the patient requests the change.
Good luck!