Resources for Physicians

The following resources for physicians were developed by Angela Hospice’s Chief Medical Officer, Dr. James Boal.

How to discuss hospice with your patient

It is sometimes difficult to discuss serious medical issues with your patient. Nonetheless, it is part of the physician’s responsibility toward the patient. Discussing hospice is particularly difficult, because it means that death is now unavoidable. Some people dislike the subject because they feel that hospice means giving up hope, or that “nothing else can be done.”

The true purpose of hospice is to do all that can be done after curative measures are no longer useful.

  • Patients have a right to know all medical options for their disease.
  • Hospice offers complete palliative care, as well as spiritual care, and social work assistance to those at the end of life.
  • For those who meet the criteria, hospice is one medical option.
  • A terminally ill patient does not have to accept hospice care, but it should be made available to them.

It is often easier to explain hospice as an option of care when the patient’s disease first begins to worsen, not as a last resort when other options have been exhausted.

  • It makes it easier for the patient to accept hospice if they have been thinking about it before it is absolutely needed.
  • People who know about hospice or have had a family member on hospice may already be considering it before it is brought up by the physician.
  • As with all difficult news and decisions, people will often have many questions and some grief to work through.
  • Physicians often need to set aside time to work through these conversations.

Discussing hospice may be difficult, but most patients wish to know the truth about their illness, allowing them to plan for their future. These conversations can often turn out to be surprisingly rewarding for the physician and patient.

If you have any questions about how to discuss hospice care with your patient, please call Dr. Jim Boal at Angela Hospice 866.464.7810.

Caring for your patient on hospice
Consistent with hospice philosophy, Angela Hospice encourages the continuation of the existing physician-patient relationship while your patient is receiving hospice services. We admire your willingness to remain involved with the care of your patient during this difficult time. Our nursing staff will look to you to provide all orders and guidance for the care of your patient.

Below you will find some basic facts to guide you as you continue to direct your patient’s plan of care.

Hospice Goal

Angela Hospice is committed to working with all people at the end of their lives. We go to every extreme to provide optimum palliative care to alleviate suffering in all its forms.  The purpose of hospice is neither to hasten death nor prolong life. We work diligently to maintain comfort and quality of life while the disease naturally progresses.

Reimbursement for Your Services
While your patient is receiving hospice services, you continue to receive the same reimbursement you previously received for your physician services. If the patient is able to come to you for an office visit or if you wish to make a home visit, you may bill the appropriate code. Even if you never see the patient you may bill insurance companies for supervising his or her care while receiving hospice services.

The Medicare billing codes for home visits and supervision are as follows:

Code (CPT) Description
99341 New Patient Straightforward in Home Care
99342 New Patient Low Complexity in Home Care
99343 New Patient Moderate Complexity in Home Care
99344 New Patient Moderate Complexity+ in Home Care
99345 New Patient High Complexity in Home Care
99347 Established Patient Straightforward in Home Care
99348 Established Patient Low Complexity in Home Care
99349 Established Patient Moderate Complexity in Home Care
99350 Established Patient High Complexity in Home Care
G0182 Physician supervision of hospice patient when patient is not present. It can be billed every month if there was 30 minutes or more of time spent on the case.

Hospice Revenues & Regulations
Angela Hospice receives reimbursement from the traditional insurance sources but primarily from Medicare. Medicare and most other insurance payers reimburse hospices on a capitated basis. Our policies, as in many other medical fields, are structured around Medicare’s regulations.

When you decide that your patient has a prognosis of six months or less, that patient may elect their insurance’s hospice benefit. This benefit entitles a patient to hospice care which includes physician services, nursing, social work, spiritual care, nurses’ aides, volunteers, bereavement, and all medication and equipment related to the terminal disease. It also entitles the patient to receive some ancillary services such as physical, speech, or occupational therapy if needed.

Hospice’s reimbursement is capitated and each insurance company pays a fixed daily amount for each patient. Out of that daily rate we pay for all aforementioned expenses. Medications and treatments for conditions other than the terminal disease may be billed separately and are not included in the daily capitated rate.

Medications and Labs
Due to the capitation, we are careful and practical about which services we provide.  It is a good idea to review the medications that a patient is on and see whether they are still useful while receiving hospice services. Many preventative or prophylactic medications, such as anti-lipids or antihypertensives are no longer needed on hospice.  We want to focus on medications used to provide comfort.

Medical Director Services
Dr. James Boal has been Angela Hospice’s full time medical director since 2000. He is double board certified in Family Practice and in Hospice and Palliative Medicine. Dr. Boal and the rest of the Angela Hospice physician team are available to answer any questions you have about hospice care. They are also available to make home visits to your patient if you so desire or are unable to see your patient.

When to refer your patient to hospice

1) The patient or DPOA understands that they have a terminal disease

    • a.They forego aggressive, curative therapy in favor of comfort care.
    • b. They desire hospice services.

2) The attending physician and the hospice medical director must both agree that the patient has six months or less to live. As this is a subjective criterion, certain guidelines have been put in place that imply a six month prognosis. A patient does not have to die in six months to be eligible for hospice; they simply need to meet the medical criteria. If your patient meets the following criteria they probably are eligible for hospice.

a. General

 i. Weight loss of >10% over the last 6 months
 ii. Serum Albumin < 2.5
 iii. Repeated hospital visits over the last few months

b. Cancer

 i. Confirmed cancer diagnosis
 ii. Patients have exhausted or refused all surgical, radiological, and  chemotherapeutic options for their disease

c. Heart Disease

 i. New York Heart Association Class IV disease: chest pain or SOB  at rest or with any movement
 ii. Patient is currently on the maximal dose of medications

d. Lung Disease

 i. SOB at rest, FEV <30% after bronchodilator, pO2 < 55

e. Liver Disease

 i. INR > 1.5 (without anticoagulants) and Serum albumin < 2.5  gm/dL
 ii. At least one of the following: jaundice, ascites, encephalopathy,  bleeding varices, hepatorenal syndrome

f. Renal Disease

i. Dialysis dependence and not seeking or eligible for dialysis

g. Dementia/Stroke

 i. Unable to walk and unable speak more than 6 different  words/day
 ii. Progressive weight loss/ poor intake

h. Neuromuscular Disease

 i. Impaired swallowing or impaired breathing due to disease or  unusually rapid progression of the disease


If you have any questions or concerns on these guidelines, please do not hesitate to contact Angela Hospice Medical Director, Dr. James Boal, at 866.464.7810.

How to refer a patient to hospice
It is a very simple process to refer your patient to Angela Hospice Home Care, Inc.

1. Contact the Referral Center by calling 888.464.2341. Staff will assist you by asking some basic medical, insurance, and demographic information about your patient.

2. Fax the referral information to the Referral Center. The fax number is 734.779.6685.

REMINDER: A physician’s order is necessary for hospice care.

If you have any questions please do not hesitate to contact the Referral Center at 888.464.2341.

The benefits of an early hospice referral

Hospice is traditionally thought to be for patients who are in the last six months of life, but some patients stay on for years if their disease process is slow. Unfortunately, half of all referrals to hospice are made within the last 15 days of a patient’s life, with many patients dying just hours after being referred to hospice care. For these patients, there is very little that can be done other than to quickly get their symptoms under control before they pass away.

Patients who are referred to hospice care early in their disease process can receive the full benefit of hospice care, including seeing their medical, social, and spiritual needs met before they die. Hospice patients only rarely need to go to the hospital or to the emergency room, as hospice staff is able to perform most treatments at home. Early referral helps give the patient and family time to plan for the upcoming death, and to be together during the end of the patient’s life.

Physicians benefit from early referrals as well, by having skilled hospice professionals help them in the care of their patients. Physicians may choose to continue to manage and follow patients while they are on hospice. Hospice physicians are also available for consult in the case of a palliative care need.

If you are unsure if it is time to refer a patient to Angela Hospice please refer to our page “When is it Time for Hospice?” or call Jim Boal, M.D., at 866.464.7810.

Treatments acceptable with hospice
Treatments acceptable with hospice care
• Feeding Tubes (all types)
• IV hydration if indicated
• Parenteral medications – IV, Subcutaneous, Intrathecal, Epidural when other routes fail
• Thoracentesis, Paracentesis
• Physical, occupational, and speech therapy when appropriate
• C-pap, Bi-pap, and oxygen
• Specialty Consults: Ophthalmology, Dermatology, Psychiatry, etc.
• Radiation therapy for pain management

Treatments generally NOT acceptable with hospice
• Oral or IV chemotherapy
• Total Parenteral Nutrition
• Blood transfusions
• Bone marrow stimulants (Epogen, Neupogen)
• Ventilators
• Cardio-pulmonary resuscitation
• Organ transplants