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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

Heath 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

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

IN FOCUS: FY2016 Proposed Hospice Payment Rule, Part 1 Clarification Regarding Diagnosis Reporting on Hospice Claims and Comments on the Hospice Bundle

May 13, 2015 04:40 PM

The National Association for Home Care & Hospice (NAHC) published an initial overview of the proposed FY2016 Hospice Payment Rule in NAHC Report on May 1, 2015.  To provide more in-depth coverage of specific elements of the proposed rule, NAHC is developing a series of “IN FOCUS” articles that will be published over the coming weeks.  Part 1 of the “IN FOCUS” series focuses on hospice diagnosis reporting and CMS’ expectations of hospice responsibilities in this regard.

As part of the proposed FY2016 Hospice Payment rule, the Centers for Medicare & Medicaid Services (CMS) clarified that hospices must report all diagnoses identified in the initial and comprehensive assessments on hospice claims, whether related or unrelated to the terminal prognosis of the individual in order that hospice practice more fully complies with ICD-9-CM and ICD-10-CM coding guidelines that all diagnoses should be included on claims, but also to ensure that hospices are conducting a thorough assessment as part of the determination of  whether an individual is terminally ill. It is the National Association for Home Care & Hospice’s (NAHC’s) understanding, from discussion with CMS, that this change is not a proposed clarification, but rather a directive to hospices that they include all diagnoses on claims.  This represents a revision to guidance previously issued by CMS that hospices should report all related diagnoses on claims. This would also include the reporting of any mental health disorders and conditions that would affect the plan of care as hospices are to assess and provide care for identified psychosocial and emotional needs, as well as, for the physical and spiritual needs.  CMS will monitor compliance with required coding practices and collaborate with all relevant CMS components to determine whether further policy changes are needed or if additional program integrity oversight actions need to be implemented. It is NAHC’s intention, as part of its comments on the FY2016 proposed payment rule to urge that CMS withhold any efforts to enforce this clarification until necessary software changes may be implemented to allow all diagnoses to flow from the patient record to hospice claims.  NAHC is seeking input from hospice providers and vendors on the time frame that would be necessary to effectuate this change; please email your comments to Theresa Forster ( or Katie Wehri (

In recent years CMS has closely followed hospice practice relative to the inclusion of diagnoses on claims; In July 2012, CMS first expressed deep concern that the vast majority of hospice claims included only a single diagnosis (77% of claims).  Subsequent study found that for the first quarter of FY2013, over 72% of hospices submitted claims with only a single diagnosis.  CMS continued to analyze codes provided on claims, and for the third quarter of FY2013 found that 69% of providers continue to submit only a single diagnosis. Most recent analysis published in the proposed FY2016 hospice payment rule indicates that hospice diagnosis coding is improving -- FY2014 claims data indicates that 49% of hospice claims list a single diagnosis.

Based on the numerous comments received in previous rulemaking, and anecdotal reports from hospices, hospice beneficiaries, and non-hospice providers discussed above, CMS is concerned that hospices may not be conducting a comprehensive assessment nor updating the plan of care as articulated by the CoPs to recognize the conditions that affect an individual’s terminal prognosis.

ICD-10-CM Coding Guidelines state that diagnoses should be reported that develop subsequently, coexist or affect the treatment of the individual. Furthermore, CMS indicates that having these diagnoses reported on claims falls under the authority granted by the Affordable Care Act to collect data to inform hospice payment reform. Having adequate data on hospice patient characteristics will help to inform thoughtful, appropriate, and clinically relevant policy for future rulemaking. CMS plans to monitor compliance with required coding practices and collaborate with all relevant CMS components to determine whether further policy changes are needed or if additional program integrity oversight actions need to be implemented.

International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10- CM) Coding Guidelines state the following regarding the selection of the principal diagnosis: The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. In the case of selection of a principal diagnosis for hospice care, this would mean the diagnosis most contributory to the terminal prognosis of the individual. In the instance where two or more diagnoses equally meet the criteria for principal diagnosis, ICD- 10-CM coding guidelines do not provide sequencing direction, and thus, any one of the diagnoses may be sequenced first, meaning to report all of those diagnoses meeting the criteria as a principal diagnosis. Per ICD-10-CM Coding Guidelines, for diagnosis reporting purposes, the definition for “other diagnoses” is interpreted as additional conditions that affect patient care in terms of requiring:

  • Clinical evaluation; or
  • Therapeutic treatment; or
  • Diagnostic procedures; or
  • Extended length of hospital stay; or
  • Increased nursing care and/or monitoring.

The UHDDS item #11-b defines Other Diagnoses as all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay. ICD-10-CM coding guidelines are clear that all diagnoses affecting the management and treatment of the individual within the healthcare setting are required to be reported. This has been longstanding existing policy. Adherence to coding guidelines when assigning ICD-9-CM and ICD-10-CM diagnosis and procedure codes is required under the Health Insurance Portability and Accountability Act (HIPAA) as well as regulations at 45 CFR 162.1002.


CMS provides comparisons of changes through the years in hospice principal diagnoses and shifts among top diagnoses.  In recent years CMS has placed increased focus on adherence to ICD-9-CM coding guidelines that prohibit use of certain diagnoses as a principal diagnosis in most cases.  These “unspecified” diagnoses include debility, adult failure to thrive, and certain dementia diagnoses.  Effective Oct. 1, 2014, CMS implemented a claims edit that returns to provider (RTPs) hospice claims using manifestation or other codes determined by the coding guidelines to be inappropriate principal diagnoses.  Data comparing FY2013 and FY2014 claims (below) indicate that -- even prior to implementation of the edit -- hospices began to respond to CMS’ direction.


FY2013 (% OF CLAIMS) 

FY2014 (% OF CLAIMS)

1. Debility Unspecified (9%)

Alzheimer’s   (9%)

2. CHF (7%)

CHF Unspecified   (8%)

3. Lung Cancer (6%)

Lung Cancer (6%)

4. COPD (6%)

COPD (6%)

5. Alzheimer’s (6%)

Senile dementia, Uncomp.  (3%)

6. Adult Failure to Thrive (5%)

Heart Disease, Unspecified (3%)

7. Senile Dementia, Uncomp. (4%)

CVA/Stroke (2%)

8. Heart Disease, Unspecified (3%)

Dementia, Unspec., w/o Behav. Disturbance

9. CVA/Stroke   (2%)

Parkinson’s   (2%)

10. Dementia in other diseases w/o Behav. Disturbance (2%)

Colon Cancer (2%)


Clarification and enforcement of the ICD-9 CM and ICD-10 coding guidelines by CMS and the proposal send a message that is much greater than the inclusion of all diagnosis codes, regardless of whether related or not, on hospice claims.  CMS commented in the proposed rule that it is concerned that some hospices are making determinations of hospice coverage based solely on cost and reimbursement as opposed to being based on patient-centered needs, preferences and goals for those approaching the end of life. CMS believes this to be counter to the holistic, comprehensive, and coordinated hospice care model promoted during the development of the Medicare hospice benefit.  CMS stated it was very clear throughout the development, and years after the implementation, of the Medicare hospice benefit that hospices were expected to make good on their promise to do a better job in the provision and coordination of care than conventional Medicare for those who were at the end of life.  However, if hospices are not making good on that promise, CMS believes it results in increased burden on hospice beneficiaries and their families— both clinically and financially—and is not in keeping with the intent of the Medicare hospice benefit as originally developed and implemented in 1983.

CMS reiterated that it has the general view that the patient’s waiver of right to curative services for the terminal diagnosis and related conditions required by the law is a broad one and that hospices are required to provide virtually all the care that is needed by terminally ill patients (48 FR 56010). Therefore, hospices are to provide pain and symptom management, as an alternative to the curative model of care, focused on the “total person” as opposed to individual disease or injury states.  CMS specifically stated, “We continue to support the philosophy of holistic, comprehensive, virtually all-inclusive hospice care and seek to protect beneficiary access and coverage under the Medicare hospice benefit.”

CMS devoted a section of the proposed rule to hospice vulnerabilities.  Here CMS cited the concerns brought forth in the Institute of Medicine (IoM) report, Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life.  CMS indicates that one of the largest barriers in providing efficient, quality end-of-life care is the lack of coordination and communication among different components of the health care system. The report states that better coordination of care is essential in improving patient outcomes and that end-of-life care should be individualized based on patient values, goals, needs, and informed preferences with a recognition that individual service needs and intensity will change over time.  CMS also cited recent news articles that identified concerns with hospice quality of care, the lack of services provided, conflicts of interest, and the current Medicare payment structure that may incentivize the provision of fewer services. Overall, the IoM report and recent news articles raise concerns regarding fragmented and uncoordinated care for those who are terminally ill.

CMS indicates that data suggests there is a significant amount of “unbundling” going on and the agency has received reports from non-hospice providers that some of the care they have provided and billed to Medicare is related to the patient’s terminal prognosis and should be part of the hospice bundle. Hospice patients have shared with CMS that they were told to revoke their hospice election to receive high-cost services that should be covered by the hospice, such as palliative chemotherapy and radiation.

CMS indicates that this information raises questions as to whether hospices are providing full disclosure of the nature of hospice care, which focuses on improving quality of life as one is approaching the end of life while eliminating the need for unnecessary, futile and possibly harmful diagnostics, treatments, and therapies. 

NAHC and its affiliate, the Hospice Association of America (HAA), recommend that hospices ensure the Medicare waiver required of hospice beneficiaries is thorough and clearly written on all admission paperwork and is also clearly and thoroughly explained to beneficiaries as they make the choice about whether to elect the Medicare hospice benefit.  We also suggest that hospices ensure a thorough comprehensive assessment to ensure the inclusion of ALL diagnoses in the hospice medical record and all diagnoses -- RELATED and UNRELATED -- on the hospice claim. There should be documentation in the patient record indicating which of these diagnoses is related to the principle diagnosis and related conditions, as well as which diagnoses are considered unrelated, and why.   Hospices must develop thoughtful processes for the hospice medical director and hospice physicians to determine what is and what is not related to the patient’s terminal illness.  NAHC is working on providing education on these topics for hospices.




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