Cigna modified MM 0462 for hospice care, effective September 26, 2025. Here's what billing teams need to know before that date.
Cigna Healthcare updated its hospice care coverage policy under MM 0462, affecting 29 CPT and HCPCS codes across every hospice care setting — from the patient's home (Q5001) to inpatient psychiatric facilities (Q5008). This modification touches advance care planning (CPT 99497, 99498), nursing services, therapy, social work, aide services, and site-of-service billing codes. If your organization bills hospice or provides services in hospice settings, audit your charge capture now.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Cigna Healthcare |
| Policy | Hospice Care |
| Policy Code | MM 0462 |
| Change Type | Modified |
| Effective Date | September 26, 2025 |
| Impact Level | High |
| Specialties Affected | Hospice and palliative care, home health, skilled nursing, social work, physical therapy, occupational therapy, speech-language pathology |
| Key Action | Audit charge capture for all 29 affected codes before September 26, 2025 and confirm medical necessity documentation meets updated criteria |
Cigna Hospice Care Coverage Criteria and Medical Necessity Requirements 2025
The Cigna hospice care coverage policy under MM 0462 defines hospice care as a program of palliative and supportive care services. It covers physical, psychological, social, and spiritual care for dying persons, their families, and loved ones.
Every code in this policy — all 29 of them — carries the same coverage designation: considered medically necessary when criteria in the applicable coverage position are met. That language matters. Medical necessity isn't assumed. It has to be established and documented before you bill.
The real issue here is documentation. Hospice billing lives and dies on your ability to show that a patient meets the qualifying criteria at each level of care. A claim denial under MM 0462 almost always traces back to missing or insufficient clinical documentation, not a coding error.
Cigna's Cigna hospice care coverage policy applies across all care settings. This includes the patient's home, assisted living, long-term care facilities, skilled nursing facilities, inpatient hospitals, inpatient hospice facilities, inpatient psychiatric facilities, and locations not otherwise specified. Each setting maps to its own site-of-service HCPCS code (Q5001 through Q5010), and you must use the right one.
Advance care planning services — CPT 99497 for the first 30 minutes and CPT 99498 for each additional 30 minutes — are also covered under this policy when medical necessity criteria are met. These codes cover the explanation and discussion of advance directives. If your team bills these codes in connection with hospice enrollment or pre-election counseling, the documentation must reflect a substantive care planning conversation, not a brief check-in.
If your billing team is uncertain how the updated medical necessity criteria apply to your specific patient population, talk to your compliance officer before September 26, 2025.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Advance care planning, first 30 minutes | Covered | CPT 99497 | Medical necessity criteria must be met |
| Advance care planning, each additional 30 minutes | Covered | CPT 99498 | Medical necessity criteria must be met |
| Physical therapy in hospice setting (per 15 min) | Covered | G0151 | Medical necessity criteria must be met |
| Occupational therapy in hospice setting (per 15 min) | Covered | G0152 | Medical necessity criteria must be met |
| Speech-language pathology in hospice setting (per 15 min) | Covered | G0153 | Medical necessity criteria must be met |
| Clinical social worker in hospice setting (per 15 min) | Covered | G0155 | Medical necessity criteria must be met |
| Home health/hospice aide in hospice setting (per 15 min) | Covered | G0156 | Medical necessity criteria must be met |
| RN management and evaluation of plan of care (per 15 min) | Covered | G0162 | Medical necessity criteria must be met |
| Direct skilled nursing — RN in hospice setting (per 15 min) | Covered | G0299 | Medical necessity criteria must be met |
| Direct skilled nursing — LPN in hospice setting (per 15 min) | Covered | G0300 | Medical necessity criteria must be met |
| Hospice pre-election evaluation and counseling | Covered | G0337 | Medical necessity criteria must be met |
| RN observation and assessment (per 15 min) | Covered | G0493 | Medical necessity criteria must be met |
| LPN observation and assessment (per 15 min) | Covered | G0494 | Medical necessity criteria must be met |
| RN patient/family training and education (per 15 min) | Covered | G0495 | Medical necessity criteria must be met |
| LPN patient/family training and education (per 15 min) | Covered | G0496 | Medical necessity criteria must be met |
| Hospice/home health care in patient's home | Covered | Q5001 | Medical necessity criteria must be met |
| Hospice care in assisted living facility | Covered | Q5002 | Medical necessity criteria must be met |
| Hospice care in nursing LTC or nonskilled NF | Covered | Q5003 | Medical necessity criteria must be met |
| Hospice care in skilled nursing facility | Covered | Q5004 | Medical necessity criteria must be met |
| Hospice care in inpatient hospital | Covered | Q5005 | Medical necessity criteria must be met |
| Hospice care in inpatient hospice facility | Covered | Q5006 | Medical necessity criteria must be met |
| Hospice care in long-term care facility | Covered | Q5007 | Medical necessity criteria must be met |
| Hospice care in inpatient psychiatric facility | Covered | Q5008 | Medical necessity criteria must be met |
| Hospice/home health care in place NOS | Covered | Q5009 | Medical necessity criteria must be met |
| Hospice home care in a hospice facility | Covered | Q5010 | Medical necessity criteria must be met |
| Hospice referral visit by nurse or social worker | Covered | S0255 | Medical necessity criteria must be met |
| End-of-life care planning and advance directive counseling | Covered | S0257 | Medical necessity criteria must be met |
| Respite care in the home, per diem | Covered | S9125 | Medical necessity criteria must be met |
| Hospice care in the home, per diem | Covered | S9126 | Medical necessity criteria must be met |
Cigna Hospice Care Billing Guidelines and Action Items 2025
The scope of this policy is broad. Twenty-nine codes across two code sets, every care setting, and multiple provider types. Here's what to do before September 26, 2025.
| # | Action Item |
|---|---|
| 1 | Audit your charge capture for all 29 affected codes. Pull every hospice-related claim from the last 90 days. Check that each claim uses the correct site-of-service Q code (Q5001–Q5010) for where care was actually delivered. A mismatch here is one of the fastest paths to a claim denial. |
| 2 | Verify your medical necessity documentation is current. Every code in MM 0462 is covered only when medical necessity criteria are met. Review your clinical documentation templates to confirm they capture what Cigna requires — not just what your EHR prompts for. |
| 3 | Review your advance care planning billing. CPT 99497 and 99498 are time-based codes. Your documentation must reflect the specific time spent and the substance of the advance directive discussion. If you bill 99498 as an add-on to 99497, make sure the total time is documented clearly. |
| 4 | Check pre-election counseling claims against G0337. G0337 covers hospice evaluation and counseling services before the patient makes the hospice election. If your team bills this code, confirm the service occurred before election, not after. Timing errors on G0337 are a common denial trigger. |
| 5 | Confirm S0255 and S0257 are coded to the right provider type. S0255 covers hospice referral visits by a nurse or social worker. S0257 covers end-of-life care planning and advance directive counseling. Both carry medical necessity requirements. Make sure your billing team links the right provider credentials to each claim. |
| 6 | Update your billing guidelines documentation. If your internal billing guidelines or payer reference materials reference MM 0462, update them to reflect the September 26, 2025 effective date. This includes any charge capture tools, claim edit rules, or pre-billing checklists. |
| 7 | Check whether prior authorization is required. The policy data does not specify prior authorization requirements at the code level, but hospice services under commercial Cigna plans often carry prior auth requirements at the plan level. Confirm your specific plan contracts before the effective date. If you're unsure, call Cigna provider relations or loop in your billing consultant. |
CPT and HCPCS Codes for Hospice Care Under MM 0462
Covered CPT Codes (When Medical Necessity Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| 99497 | CPT | Advance care planning including explanation and discussion of advance directives such as standard forms (with or without completing standard form), first 30 minutes |
| 99498 | CPT | Advance care planning including explanation and discussion of advance directives such as standard forms (with or without completing standard form), each additional 30 minutes |
Covered HCPCS Codes (When Medical Necessity Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| G0151 | HCPCS | Services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes |
| G0152 | HCPCS | Services performed by a qualified occupational therapist in the home health or hospice setting, each 15 minutes |
| G0153 | HCPCS | Services performed by a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes |
| G0155 | HCPCS | Services of clinical social worker in home health or hospice setting, each 15 minutes |
| G0156 | HCPCS | Services of home health/hospice aide in home health or hospice settings, each 15 minutes |
| G0162 | HCPCS | Skilled services by a registered nurse (RN) for management and evaluation of the plan of care, each 15 minutes |
| G0299 | HCPCS | Direct skilled nursing services of a registered nurse (RN) in the home health or hospice setting, each 15 minutes |
| G0300 | HCPCS | Direct skilled nursing services of a licensed practical nurse (LPN) in the home health or hospice setting, each 15 minutes |
| G0337 | HCPCS | Hospice evaluation and counseling services, pre-election |
| G0493 | HCPCS | Skilled services of a registered nurse (RN) for the observation and assessment of the patient's condition, each 15 minutes |
| G0494 | HCPCS | Skilled services of a licensed practical nurse (LPN) for the observation and assessment of the patient's condition, each 15 minutes |
| G0495 | HCPCS | Skilled services of a registered nurse (RN), in the training and/or education of a patient or family member, each 15 minutes |
| G0496 | HCPCS | Skilled services of a licensed practical nurse (LPN), in the training and/or education of a patient or family member, each 15 minutes |
| Q5001 | HCPCS | Hospice or home health care provided in patient's home/residence |
| Q5002 | HCPCS | Hospice or home health care provided in assisted living facility |
| Q5003 | HCPCS | Hospice care provided in nursing long-term care facility (LTC) or nonskilled nursing facility (NF) |
| Q5004 | HCPCS | Hospice care provided in skilled nursing facility (SNF) |
| Q5005 | HCPCS | Hospice care provided in inpatient hospital |
| Q5006 | HCPCS | Hospice care provided in inpatient hospice facility |
| Q5007 | HCPCS | Hospice care provided in long-term care facility |
| Q5008 | HCPCS | Hospice care provided in inpatient psychiatric facility |
| Q5009 | HCPCS | Hospice or home health care provided in place not otherwise specified (NOS) |
| Q5010 | HCPCS | Hospice home care provided in a hospice facility |
| S0255 | HCPCS | Hospice referral visit (advising patient and family of care options) performed by nurse, social worker, or other designated staff |
| S0257 | HCPCS | Counseling and discussion regarding advance directives or end-of-life care planning and decisions, with patient and/or surrogate |
| S9125 | HCPCS | Respite care, in the home, per diem |
| S9126 | HCPCS | Hospice care, in the home, per diem |
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