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In the various roles he has undertaken through the years, Val J. Halamandaris has been a singular driving force behind the policy and program initiatives resulting in the recognition of home health care as a viable alternative to institutionalization. His dedication to consumer advocacy, which enhances the quality of life and dignity of those receiving home health care, merits VNA HealthCare Group’s highest recognition and deepest respect. 

VNA HealthCare Group

I have the highest respect for them, especially for the nurses, aides and therapists, who devote their lives to caring for people with disabilities, the infirm and dying Americans.  There are few more noble professions.

President Barack Obama

Home health care agencies do such a wonderful job in this country helping people to be able to remain at home and allowing them to receive services

U.S. Senator Debbie Stabenow (D-MI) Chair, Democratic Steering and Outreach Committee

Home care is a combination of compassion and efficiency.  It is less expensive than institutional care...but at the same time it is a more caring, human, intimate experience, and therefore it has a greater human’s a big mistake not to try to maximize it and find ways to give people the home care option over either nursing homes, hospitals or other institutions

Former Speaker of the U.S. House of Representatives Newt Gingrich (R-GA)

Medicaid covers long-term care, but only for low-income families.  And Medicare only pays for care that is connected to a hospital discharge....our health care system must cover these vital services...[and] we should promote home-based care, which most people prefer, instead of the institutional care that we emphasize now.

Former U.S. Senator Majority Leader Tom Daschle (D-CD)

We need incentives to...keep people in home health care settings...It’s dramatically less expensive than long term care.

U.S. Senator John McCain (R-AZ)


Home care is clearly the wave of the future. It’s clearly where patients want to be cared for. I come from an ethnic family and when a member of our family is severely ill, we would never consider taking them to get institutional care. That’s true of many families for both cultural and financial reasons. If patients have a choice of where they want to be cared for, where it’s done the right way, they choose home.

Donna Shalala, former Secretary of Health and Human Services

A couple of years ago, I spent a little bit of time with the National Association for Home Care & Hospice and its president, Val J. Halamandaris, and I was just blown away. What impressed me so much was that they talked about what they do as opposed to just the strategies of how to deal with Washington or Sacramento or Albany or whatever the case may be. Val is a fanatic about care, and it comes through in every way known to mankind. It comes through in the speakers he invites to their events; it comes through in all the stuff he shares.

Tom Peters, author of In Search of Excellence

Val’s home care organization brings thousands of caregivers together into a dynamic organization that provides them with valuable resources and tools to be even better in their important work. He helps them build self-esteem, which leads to self-motivation.

Mike Vance, former Dean of Disney and author of Think Out of the Box

Val is one of the greatest advocates for seniors in America. He goes beyond the call of duty every time.

Arthur S. Flemming, former Secretary of Health, Education, and Welfare

Val has brought the problems, the challenges, and the opportunities out in the open for everyone to look at. He is a visionary pointing the direction for us. 

Margaret (Peg) Cushman, Professor of Nursing and former President of the Visiting Nurses Association

Although Val has chosen to stay in the background, he deserves much of the credit for what was accomplished both at the U.S. Senate Special Committee on Aging, where he was closely associated with me and at the House Select Committee on Aging, where he was Congressman Claude Pepper’s senior counsel and closest advisor. He put together more hearings on the subject of aging, wrote more reports, drafted more bills, and had more influence on the direction of events than anyone before him or since.

Frank E. Moss, former U.S. Senator

Val’s most important contribution is pulling together all elements of home health care and being able to organize and energize the people involved in the industry.

Frank E. Moss, former U.S. Senator

Anyone working on health care issues in Congress knows the name Val J. Halamandaris.

Kathleen Gardner Cravedi, former Staff Director of the House Select Committee on Aging

Without your untiring support and active participation, the voices of people advocating meaningful and compassionate health care reform may not have been heard by national leaders.

Michael Sullivan, Former Executive Director, Indiana Association for Home Care

All of us have been members of many organizations and NAHC is simply the best there is. NAHC aspires to excellence in every respect; its staff has been repeatedly honored as the best in Washington; the organization lives by the highest values and has demonstrated a passionate interest in the well-being of patients and providers.

Elaine Stephens, Director of Home Care of Steward Home Care/Steward Health Systems and former NAHC C

Home care increasingly is one of the basic building blocks in the developing system of long-term care.  On both economic and recuperative bases, home health care will continue to grow as an essential service for individuals, for families and for the community as a whole.

Former U.S. Senator Olympia Snowe (R-ME)

NCOA is excited to be part of this great event and honored to have such influential award winners in the field of aging.

National Council of Aging

Health care at home…is something we need more of, not less of.  Let us make a commitment to preventive and long-term care.  Let us encourage home care as an alternative to nursing homes and give folks a little help to have their parents there.

Former President Bill Clinton

Hospice FY2014 Payment, Wage Index Final Rule Issued: Debility, AFTT Prohibited as Principal Diagnoses Starting October 1, 2014 (PART ONE)

Part One
August 6, 2013 10:13 AM


On August 2, the Centers for Medicare & Medicaid Services (CMS) issued a final rule: Medicare Program; FY2014 Hospice Wage Index and Payment Rate Update; Hospice Quality Reporting Requirements; and Updates on Payment Reform.  The final rule is scheduled for publication in the Federal Register on August 7, 2013. 

FY2014 wage index tables are available in the downloads section of CMS’ website here.

The final rule addresses:

  • Updates to hospice payment rates and wage index effective for fiscal year (FY) 2014.  Hospices will net an update of 1.0 percent after taking into account Affordable Care Act reductions and changes to the wage index - including the fifth year of the phase-out of the budget neutrality adjustment factor
  • A number of issues related to diagnosis reporting on hospice claims, including:
    • Further expresses CMS’ expectation that hospices will include a principal diagnosis and all related coexisting diagnoses on claims
    • Clarifies CMS’ intent to return to provider (RTP), effective for claims submitted on or after Oct. 1, 2014, hospice claims with either Debility or Adult Failure to Thrive (AFTT) listed as the principal diagnosis
    • Cautions hospices that a number of diagnoses for “dementia” are inappropriate for use as principal diagnoses on hospice claims
  • For the hospice quality reporting program (HQRP):
    • Confirms CMS’ intent to eliminate collection of the structural measure and NQF0209 at the end of calendar year 2013
    • Finalizes CMS’ plans to begin collection of the Hospice Item Set (HIS) starting in July 2014
    • Indicates that CMS will begin collection of data related to the Hospice Experience of Care Survey beginning January 1, 2015, and,
  • Provides an update on hospice payment reform


As part of the final rule, CMS provides statistics and commentary on Medicare hospice utilization.  The number of Medicare beneficiaries receiving hospice care has grown from 513,000 in FY2000 to over 1.3 million in FY2012.  Medicare hospice expenditures have risen from $2.9 billion in FY2000 to $14.7 billion in FY2012.  CMS’ Office of the Actuary projects that hospice outlays will continue to grow at a rate of approximately 8 percent annually.  While CMS outlines a number of reasons for this growth, they indicate that the increase is partly due to an increased average lifetime length of stay from 54 days in 2000 to 86 days in FY2010 - an increase of 59 percent. 

CMS also cites notable changes in diagnosis patterns in the areas of neurologically-based diagnoses, including various dementia diagnoses, as well as significant increases in the use of non-specific, symptom-classified diagnoses, such as Debility and AFTT.

Diagnosis Reporting on Hospice Claims

As referenced in the FY2013 Hospice Wage Index Notice and in the FY2014 proposed rule, CMS once more addressed concerns and requirements related to hospice diagnosis coding and reporting on claims. CMS indicates that its statements reflect clarification of coding rules and guidance, and are not intended to preclude the physician’s clinical judgment in determining a beneficiary’s eligibility for hospice services. 

In the final rule, CMS announced that, effective for claims submitted on or after October 1, 2014, a principal diagnosis of Adult Failure to Thrive (AFTT) or Debility on a hospice claim will cause the claim to be returned to provider (RTP) for clarification (use of an appropriate principal diagnosis).

It is anticipated that a Change Request implementing this action will be issued in the very near future.  NAHC/HAA have advised hospices to instruct their physicians to examine current and admitting cases of AFTT and Debility to establish alternative principal diagnoses that, based on CMS’ concerns, better reflect the underlying cause of condition(s) that are the principal (or part of the principal) cause for treatment under hospice and lead to the expectation that the patient has six months or less to live if the illness runs its normal course.

As part of the final rule in the section on hospice diagnosis coding CMS specifically addresses ICD-9-CM coding guidelines; use of nonspecific, symptom diagnoses; use of Mental, Behavioral and Neurodevelopmental Disorders; guidance on coding of principal and other, additional, and/or coexisting diagnoses; and transition to ICD-10-CM.  Following are specific comments and concerns from the final rule that hospice providers may find helpful.

Adherence to ICD-9-CM Guidelines (Multiple Diagnoses on Claims)

CMS iterates that “all providers are required to code and report the principal diagnosis as well as all coexisting and additional diagnoses related to the terminal condition or related conditions to more fully describe the Medicare patients they are treating.”  CMS indicates that this is part of compliance with the Health Insurance Portability and Accountability Act (HIPAA), ICD-9-CM guidelines and instructions in the Medicare Claims Manual. 

In July 2012, CMS first expressed deep concern that the vast majority of hospice claims included only a single diagnosis (77 percent of claims).  Subsequent study found that for the first quarter of FY2013, over 72 percent of hospices submitted claims with only a single diagnosis.  CMS has continued to analyze codes provided on claims, and for the third quarter of FY2013 found that 69 percent of providers continue to submit only a single diagnosis. 

NAHC/HAA has alerted CMS that some software prohibits the transfer of more than one diagnosis to the claim or does not distinguish between related and non-related diagnoses and that most vendors have either addressed or are in the process of addressing the issue(s). 

CMS instructs that hospices should enter into conversations with their vendors to ensure that the principal and all diagnoses related to it are transferring to the claim.  Additionally, hospices should analyze their clinical practices to ensure that the hospice physician is identifying the principal and all other diagnoses related to the terminal condition.  

CMS indicates in the rule that “while hospice physicians use their clinical judgment to determine the principal diagnosis and related conditions, we do not require them to determine the actual codes associated with those diagnoses for inclusion on the hospice claim.  Hospices have the flexibility to determine how to take the physicians’ information about diagnoses and translate it into the appropriate codes on the claim (emphasis added).”

While CMS has not indicated its intention to take specific action related to failure to supply more than a single diagnosis on claims at this time, it is clear that CMS will continue to monitor hospice practice related to diagnosis reporting on claims, and future action is possible.

CMS has indicated that inclusion of multiple diagnoses on hospice claims is required under guidelines and the Claims Manual, and that this data could be used for payment reform, but CMS also notes serious concerns related to potential unbundling of services under hospice.  For example, CMS and others have identified instances of drugs being charged to Medicare’s Part D program that are believed to be related to hospice care - and therefore are the financial responsibility of the hospice. 

NAHC/HAA expects that this will be an area of ongoing study and inquiry by CMS, the Office of the Inspector General, and others. 

CMS states in the rule that,

“The comprehensive assessment must take into consideration the following factors:  the nature and condition causing admission (including the presence or lack of objective data and subjective complaints); complications and risk factors that affect care planning; functional status’ imminence of death; and the severity of symptoms.  The Medicare Hospice Benefit requires the hospice to cover all reasonable and necessary palliative care related to the terminal prognosis and related conditions, as described in the patient’s plan of care…Clinically, related conditions are any physical or mental conditions that are related to or caused by either the terminal illness or the medications used to manage the terminal illness...It is often not a single diagnosis that represents the terminal prognosis of the patient, but the combined effect of several conditions that makes the patient’s condition terminal….we believe that the unique physical condition of each terminally ill individual makes it necessary for these decisions to be made on a case-by-case basis.  It is our general view that hospices are required to provide virtually all the care that is needed by terminally ill patients.  Therefore, unless there is clear evidence that a condition is unrelated to the terminal prognosis, all services would be considered related.  It is also the responsibility of the hospice physician to document why a patient’s medical needs would be unrelated to the terminal prognosis.”

Use of Non-specific, Symptom Diagnoses (AFTT/Debility)

CMS states that there have been noted changes in the diagnosis patterns related to hospice, including significant increases in the use of non-specific, symptom-classified diagnoses, such as “debility” and “adult failure to thrive (AFTT).”  In FY2012, both Debility and AFTT were in the top five claims-reported hospice diagnoses and were the first and third most common hospice diagnoses, respectively.  Debility and AFTT are both contained under the ICD-9-CM Coding classification “Symptoms, Signs and Ill-defined Conditions.” As part of the proposed rule, CMS clarified that Debility and AFTT are not considered appropriate principal diagnoses for hospice, although they may be used on the hospice claim as other, additional, or coexisting diagnoses.

CMS indicates, “a hallmark clinical characteristic of both Debility and AFTT is the presence of multiple primary conditions.”  The principal diagnosis reported should be the condition determined by the certifying hospice physician(s) as the diagnosis most contributory to the terminal decline. 

Effective with claims submitted on or after October 1, 2014, CMS’ contractors will RTP hospice claims that include Debility or AFTT as the principal diagnosis.  Hospices will be expected to resubmit the claims with a more appropriate principal diagnosis.  A Change Request providing additional detail is anticipated at any time. 

CMS indicates that it will continue to work with the contractors to ensure that all LCDs will reflect these coding clarifications and that the collaborations will not be limited to the release of Change Requests.  CMS stresses several times in comments throughout the Final Rule that it is the patient’s prognosis, not diagnosis, that determines eligibility for hospice care.

CMS indicates that hospices would not be required to establish a new Certificate of Terminal Illness “simply because a beneficiary’s principal diagnosis changes.”

CMS also states

“In the rare event that no single definitive terminal diagnosis (or diagnoses) can be determined by the certifying physician, whether from lack of clinical documentation or patient refusal for diagnostic work-up, then the expectation would be that all conditions that are present at the time of hospice certification that deem the individual as terminally ill would be reported on the hospice claim…

Oftentimes, if an individual has reported a past, resolved problem in their medical history, and that problem could cause the symptom syndromes of ‘debility’ or ‘adult failure to thrive’, that problem is the most likely one underlying the patient’s presentation.  The expectation remains that hospice providers, using their best clinical judgment, knowledge, and expertise, will ‘paint’ a detailed picture of their patients to more fully describe Medicare hospice patients.  

If a Medicare beneficiary is reported to be ‘dying of old age’ or ‘otherwise healthy, but elderly,’ [CMS] believes that characterization of the beneficiary’s condition is inconsistent with classifying the individual as terminally ill….advanced age alone is inadequate documentation of terminal prognosis.”

ABT Associates recently conducted research for CMS related to use of AFTT and Debility as the only diagnosis on hospice claims and found that over 50 percent of the hospice beneficiaries had seven or more chronic conditions and 75 percent had four or more chronic conditions.  “The individual diagnosed with Debility or AFTT may have multiple comorbid conditions that individually may not deem the individual to be terminally ill.  However, the collective presence of these multiple comorbid conditions will contribute to the terminal prognosis of the individual.” 

CMS has indicated that while they are taking action related to only Debility and AFTT at this time, they will continue to monitor the diagnostic coding patterns on hospice claims related to “Symptoms, Signs and Ill-defined Conditions” for any further issues or clarifications that may be needed.

Use of Dementia Codes

In the proposed rule CMS discussed concerns related to the use of certain dementia codes, particularly several that fall under the ICD-9-CM classification, “Mental, Behavioral and Neurodevelopmental Disorders.”  CMS restates in the final rule that there are several codes under this classification (which are most commonly a secondary manifestation of an underlying causal condition) that are frequently reported principal hospice diagnoses but are not appropriate based on ICD-9-CM Coding Guidelines. 

CMS again indicates that for those dementia codes under this classification that are considered “manifestation” codes, ICD-9-CM requires that the underlying condition(s) be sequenced first, followed by the manifestation. 

In cases where a code is considered a manifestation code, it generally will include a notation in the title, such as “in diseases classified elsewhere”, which indicates that the underlying, causative diagnosis should be listed prior to the manifestation.  CMS clarifies that two of the most frequently reported dementia codes – “dementia in conditions classified elsewhere with behavioral disturbance” and “dementia in conditions classified elsewhere without behavioral disturbance” – are NOT to be used as a principal diagnosis for hospice purposes - although they can be used as additional codes on claims. 

Two other dementia codes – those for “senile dementia, uncomplicated” and “other persistent mental disorders due to conditions classified elsewhere” – are also NOT appropriate as principal diagnoses.  CMS will not take action on claims with these diagnosis at this time, but it is clear from comments in the Final Rule that it is paying close attention to these types of diagnoses as the principal diagnosis on hospice claims.

A number of dementia codes are also found under “Diseases of the Nervous System and Sense Organs.”   Some of these codes are appropriate as principal diagnoses – including Alzheimer’s Disease, Lewy-Body Dementia, fronto-temporal dementia, and senile degeneration of the brain (CMS does not provide a comprehensive list).   However, it is important that hospices pay close attention to instructions and notations included as part of ICD-9-CM to ensure that they are using codes that are appropriate as principal diagnoses. 

Coding Patients with Inpatient Admissions

In the proposed rule CMS indicated that it would expect that the circumstances of an inpatient admission occurring within a short time of election of hospice would “always govern the selection of principal diagnosis”.  CMS notes in the final rule that the principal hospice diagnosis may not mirror the inpatient hospital diagnosis in certain circumstances for good reason, but that hospices should use caution to ensure that the reason for a recent inpatient admission is considered when establishing hospices diagnoses for reporting on claims.

Transition to ICD-10

CMS notes that understanding crosswalking will be important to physicians during the transition phase to ICD-10-CM; however, hospices should NOT substitute crosswalking for learning and fully implementing ICD-10-CM in their procedures. 

Hospice Wage Index and Rate Updates

In FY2014 hospice payments will increase by a net 1.0 percent.  This figure is derived from use of the final hospital market basket update (2.5 percent) less Affordable Care Act reductions (a productivity adjustment of 0.5 percentage point and an additional 0.3 percentage point reduction) that total 0.8 percentage points, and taking into account wage index changes that further reduce overall payments by 0.7 percentage point (including the fifth year of the phase out of the BNAF).

As indicated above, the tables for the FY2014 hospice wage index values (based on the 2013 hospital wage index) are available on the CMS website here in the downloads section.  Wage index values are no longer published in the Federal Register. These values do not reflect the Office of Management and Budget’s new area delineations, which may be applied in a future payment year. 

Labor/Non-labor Portion of FY 2014Hospice Payment Rates (note:  does not reflect changes in the wage index or impact of sequester)


Level of Care



Routine Home Care

68.71 percent

31.29 percent

Continuous Home Care



General Inpatient







Final FY2014 Hospice Payment Rates Updates by Final Hospice Payment Update Percentage



FY2013 Payment Rates

Multiply by the FY2014 final hospice payment update of 1.7 percent

FY2014 final Payment Rate


Routine Home Care


x 1.017



Continuous Home Care

Full rate:24 hours of care

$=$37.95 hourly rate


x 1.017



Inpatient Respite Care


x 1.017



General Inpatient Care


x 1.017



Hospices are reminded that failure to submit required data for the HQRP will result in a 2-percentage point reduction in their payment update.  A Change Request with the finalized FY2014 payment rates, the final FY2014 wage index, the FY2014 PRICER, and the hospice cap amount for the cap year ending October 31, 2013, will be issued in the near future.




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