Coding with Clarity: How HOPE is Transforming Hospice Documentation

With the introduction of the Hospice Outcomes and Patient Evaluation (HOPE) tool, the hospice industry is entering a new era, one defined by enhanced documentation standards, evolving expectations for diagnosis coding, and a renewed emphasis on delivering holistic care.  

Coding History: From Simplicity to Specificity 

To understand the importance of HOPE, it helps to look back at the progression of hospice coding. As recently as 2012, more than three-quarters of hospice claims listed just one diagnosis. CMS began raising concerns that year, reminding providers that all diagnoses, terminal and related, should be included in the hospice plan of care, even if only terminal and related diagnoses appeared on the claim. 

By 2015, CMS had shifted from encouragement to enforcement. As part of the transition to ICD-10, CMS required hospices to list terminal, related and unrelated diagnoses on claims. This shift was driven largely by concern over unbundled services: situations where hospice-eligible care was instead billed to Medicare outside of the hospice benefit, leading to significant financial strain for both the Medicare program and patients’ families. 

The message from CMS has remained consistent: hospice is holistic. Providers are expected to treat and code for the whole patient, not just the terminal diagnosis. Virtually all services are related, and any diagnoses marked as unrelated must be supported by strong clinical documentation from the hospice physician. 

HOPE’s Arrival: What’s New? 

While the previous Hospice Item Set (HIS) included only a handful of options for principal diagnosis, HOPE introduces a more nuanced set of coding expectations. Now, providers must specify diagnoses such as stroke, neurological conditions, liver disease, renal disease and others, creating a clearer picture of what brought a patient to hospice care. 

HOPE requires two layers of diagnosis documentation: 

• Principal Diagnosis: The condition chiefly responsible for the patient’s admission to hospice, based on available clinical documentation. 
• Comorbidities and Coexisting Conditions: Conditions present at the time of admission or that impact the plan of care. This includes both related and unrelated diagnoses. 

It is important to align HOPE responses with clinical documentation and coding guidelines. For instance, if a patient has end-stage renal disease (ESRD) and diabetes, CMS coding conventions dictate that diabetes (E11.22) be listed first, followed by the renal disease (N18.6). However, HOPE’s principal diagnosis should reflect the terminal condition most directly tied to hospice eligibility, which in this case is ESRD. 

Following the Coding Rules 

Under HOPE, hospice providers must adhere strictly to ICD-10 coding conventions. This includes sequencing requirements and documentation rules that may seem unfamiliar to clinicians outside the coding field. A few key conventions include: 

• “With” and “In” Conventions: ICD-10 assumes certain conditions are related when linked by these terms in the code index. For example, “diabetes with chronic kidney disease” is presumed related and must be coded in a specific order—even without provider documentation explicitly stating the connection. 
• Etiology/Manifestation Pairs: Manifestation codes cannot be used as principal diagnoses. Instead, they must follow the underlying cause. For example, dementia due to Parkinson’s must be coded with Parkinson’s first. 
• Prohibited Diagnoses: Certain symptom-based codes like debility or adult failure to thrive can no longer be used as principal diagnoses. CMS has also disallowed Z codes (e.g., for aftercare or palliative care) as primary entries on hospice claims. 

By staying within these coding parameters, hospices reduce the risk of denials, audits and compliance issues while helping claims accurately reflect the complexity of patient care. 

Documentation: Beyond the Codes 

Accurate coding is only part of the picture. The hospice plan of care and the new election statement addendum are key components for compliance and quality care delivery. If a patient or their family requests it, hospices must be prepared to clearly articulate which conditions are considered unrelated and explain why certain drugs or services are not being covered under the hospice benefit. This requirement reinforces the importance of clear, thorough and patient-centered documentation practices. 

Hospice providers must also maintain ongoing communication with non-hospice providers involved in a patient’s care. CMS expects hospice teams to coordinate with outside specialists or physicians furnishing care for conditions deemed unrelated, though again, the bar for proving a condition is unrelated remains high. 

HOPE’s Impact on the Future 

The introduction of HOPE is not merely a documentation update; it reflects a broader shift in CMS’s vision for hospice care. By requiring greater specificity in diagnoses and encouraging robust documentation of all conditions impacting care, CMS aims to align hospice practices with its core goal: delivering comprehensive, high-quality, patient-centered services in the final stages of life. 

To navigate this new landscape, hospice agencies must invest in education, training and process improvements. Coders and clinicians alike need to understand how documentation affects compliance and reimbursement, and how coding choices reflect the reality of patient care. 

Embracing these changes isn’t about making life harder for providers; it’s about supporting holistic patient care and making sure hospice agencies are equipped and reimbursed to deliver it.

About the Author

Lisa Selman-Holman, VP of Clinical Services

Lisa Selman-Holman is the VP of Clinical Services at McBee, bringing over 39 years of expertise in home health and hospice. As a registered nurse and home care attorney, she specializes in regulatory compliance. Lisa has held various roles, from field nurse to executive, managing accreditation surveys, acquisitions, and regulatory crises. In 2004, she founded Selman-Holman & Associates, offering consulting, coding and OASIS review services. Lisa is a renowned educator, known for turning challenges into achievements. Joining McBee in 2021, she acts as VP of Clinical Services. In this role, Lisa oversees the clinical aspects of consulting projects, providing expert advice on clinical operations, quality improvement, patient care standards, and regulatory compliance to healthcare organizations, while also playing a key role in business development by identifying potential clients and shaping consulting proposals based on their clinical needs.