T2042, Hospice routine home care; per diem
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Required documentation (as specified in Criteria I) must be submitted.
- Documentation demonstrating terminal diagnosis and expected life expectancy of six months or less.
- Documentation of hospice medical director certification of hospice appropriateness for the initial 90-day certification period
- Written certification must identify the terminal illness diagnosis that prompted the member/enrollee to seek hospice care
Key Coverage Criteria
- Home hospice services are consideredmedically necessarywhenbothof the following criteria (A and B) below are met:
- The individual requires hospice care, as evidenced by meetingbothof the following criteria (1 and 2):The individual is terminally ill (for example, life expectancy is 6 months or less if illness runs its normal course);andThe individual requires services for the management of a terminal illness and related condition(s).and
- The individual is terminally ill (for example, life expectancy is 6 months or less if illness runs its normal course);and
- The individual requires services for the management of a terminal illness and related condition(s).and
- The individual requireseitherof the following:Routine home hospice services: Services required for less than 8 hours of predominantly nursing care during a 24-hour day, which begins and ends at midnight;orContinuous home care services: Services required whenbothof the following criteria (a and b) are met:The individual requires a minimum of 8 hours of nursing, hospice aide, or homemaker care during a 24-hour day*, which begins and ends at midnight.andThe continuous home care services are provide [...]
- Routine home hospice services: Services required for less than 8 hours of predominantly nursing care during a 24-hour day, which begins and ends at midnight;or
2 Active Policies
ANTHEM-CG-MED-101, CG-MED-101 Home Hospice
AMBETTER-CP.MP.54, Hospice Services
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.