HOPE Assessment Tool Blog Series: All About Active Diagnoses
HOPE Assessment Tool Blog Series: All About Active Diagnoses
The implementation date of the HOPE assessment is now five months away and providers should be well on the path for readiness. As a reminder, the Centers for Medicare and Medicaid Services (CMS) posted updated final HOPE materials on April 22, 2025 including the revised HOPE Guidance Manual v1.01. Amended information in the HOPE manual should be incorporated into staff training leading up to October 1, 2025. Providers should also check in with their electronic medical record (EMR) vendor to ensure they have updated their HOPE tool appropriately with information from the v1.01 manual.
This blog series has been working its way through the domains of the HOPE assessment tool and this edition will discuss patient diagnoses and health conditions. At this point in the comprehensive assessment, a clinician has collected administrative and patient preference data. Using a patient’s referral information and patient and family interview, a clinician collects more information about the patient’s clinical history including active diagnoses and other health conditions.
Active diagnoses
This domain (Section I) and its items refer to the patient’s primary diagnosis and any active co-morbidities. It includes the most common principal diagnoses among hospice patients, as well as comorbidities and co-existing conditions. Information collected during the initial and ongoing comprehensive assessments helps the certifying hospice physician determine the correct primary or terminal diagnosis(s) and other health conditions that will impact the terminal prognosis, the plan of care, and service delivery.
It is important for clinicians to collect all active diagnoses which assist the certifying hospice physician in determining which comorbidities or health conditions are related or contribute to the terminal prognosis. Hospice providers are responsible for providing all items and services needed for the palliative care and managing the terminal illness and related conditions per federal regulatory requirements. All care/items/services that are determined as non-covered should be discussed with the patient and family/caregiver at admission and throughout the hospice stay. And the hospice provider should offer an election statement addendum if there are conditions, items, services, and drugs determined to be unrelated to the individual’s terminal illness and related conditions and will not be covered by the hospice.
All requirements for compliance with § 418.24 Election of hospice care are located in the Hospice eCFR. Regulations at 42 CFR 418.202 describe covered services under the hospice benefit.
HIS to HOPE
When comparing the Hospice Item Set (HIS) diagnosis item to the HOPE, CMS expanded the original data element and included a new “check all that apply,” list for comorbidities and co-existing conditions. The expanded list of principle/primary diagnoses and comorbidities is now more in line with Local Coverage Determinations (LCDS) that are developed by the hospice Medicare Administrative Contractors (MAC).
| HIS | HOPE |
|---|---|
| I0010. Principal Diagnosis 01. Cancer 02. Dementia/Alzheimer’s 99. None of the above | I0010. Principal Diagnosis 01. Cancer 02. Dementia (including Alzheimer’s disease) 03. Neurological Condition (e.g., Parkinson’s disease, multiple sclerosis, amyotrophic lateral sclerosis (ALS)) 04. Stroke 05. Chronic Obstructive Pulmonary Disease (COPD) 06. Cardiovascular (excluding heart failure) 07. Heart Failure 08. Liver Disease 09. Renal Disease 99. None of the above Comorbidities and Co-existing Conditions (Check all that apply) Cancer I0100. Cancer Heart/Circulation I0600. Heart Failure (e.g., congestive heart failure (CHF) and pulmonary edema) I0900. Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD) I0950. Cardiovascular (excluding heart failure) Gastrointestinal I1101. Liver disease (e.g., cirrhosis) Genitourinary I1510. Renal disease Infections I2102. Sepsis Metabolic I2900. Diabetes Mellitus (DM) I2910. Neuropathy Neurological I4501. Stroke I4801. Dementia (including Alzheimer’s disease) I5150. Neurological Conditions (e.g., Parkinson’s disease, multiple sclerosis, ALS) I5401. Seizure Disorder Pulmonary I6202. Chronic Obstructive Pulmonary Disease (COPD) Other I8005. Other Medical Condition |
The primary diagnosis
The patient’s primary or terminal diagnosis is the one that contributes the most to the patient’s life expectancy of six months or less if the illness runs its normal course and the diagnosis that the hospice physician would record on the death certificate. For purposes of the HOPE diagnoses item, CMS defines the principal diagnosis as the condition established after reviewing all available information chiefly responsible for the patient’s admission and is based on the patient’s principal diagnosis at the time of admission to hospice. According to the HOPE manual, clinicians are required to review the clinical record for details on the principal diagnosis. They must complete this item based on the data within the clinical record and not use any external sources of information. Providers must also report the principal/primary diagnosis on claims as the diagnosis most related to the terminal prognosis.
In March 2025, CMS posted Change Request 13882, “Principal Diagnosis Code Reporting Update for Hospice and Manual Updates to Sections 30.3, 40.2, and 50 of Chapter 11 of the Claims Processing Manual: Processing Hospice Claims” which provides an updated list of unacceptable principal diagnosis codes under the hospice benefit and updates information in section 30.3 of the CMS Chapter 11, Hospice Claims Processing Manual. The FY 2025 ICD-10-CM Official Guidelines for Coding and Reporting specify that codes for symptoms, signs, and ill-defined conditions from Chapter 18 must not be used as the principal diagnosis if a related definitive diagnosis has been determined. Appendix A in the Change Request provides a list of invalid principal/primary diagnosis codes. If any of these codes are used as a principal/primary diagnosis on a claim form, Providers who report an invalid diagnosis as the principal/primary diagnosis on a claim, the MAC will return the claim.
In the recent update to the HOPE manual, CMS made a clarification to this item’s example that explains how to address any circumstance where a hospice patient may have both a primary and a secondary cancer (comorbidity). This example appears on page 55 of the updated manual. There are also coding tips to guide the clinician in completing the item.
Comorbidities and Coexisting Conditions
CMS advises clinicians to review the medical record or other available patient information to discover any comorbidities and/or coexisting conditions at the time of admission to hospice. Instructions direct the clinician to check all comorbid and/or coexisting diseases or medical conditions that will be addressed in the plan of care or that have the potential to impact the plan of care. The certifying hospice physician will review the comorbidities and/or coexisting conditions at the time of admission to determine which are related to the terminal prognosis. All diagnoses must be reported on the hospice claim form which can support up to twenty-five diagnoses.
Hospice interdisciplinary groups/teams, including the hospice and attending physician (if any) should review the principle/primary and comorbidities and/or coexisting conditions throughout the patient service period to determine if changes are required. It is possible for the principle/primary diagnosis to change depending on the disease trajectory of the primary diagnosis and related and comorbidities and/or coexisting conditions. If a change is required for the principle/primary diagnosis, there is no need to resubmit a new Notice of Election form to your MAC. The updated diagnosis can be included on the claim form when it’s submitted.
Strategies for Success
Determining and recording accurate information in the HOPE assessment tool about active diagnoses establishes patient eligibility for hospice services and is an important factor in building an individualized plan of care. Some strategies for success related to this HOPE item include:
- Ensure admission nurses receive education about the content in the Active Diagnoses section of the HOPE manual and its associate items.
- Ensure admission nurses are taught and understand where to collect information about the principle/primary and comorbidities and/or coexisting conditions and how to record it on the HOPE assessment
- An EMR vendor should teach hospice staff about the format completion of the HOPE assessment items in a targeted education session
- Ensure hospice physicians have all data necessary to determine hospice eligibility and the principle/primary and comorbidities and/or coexisting conditions to determine relatedness and their contribution to the terminal prognosis
- Remember – a physician determines relatedness, not the Administrator, CEO or CFO
- Physicians should review Appendix A, “Invalid Hospice Principal Diagnosis Codes” in CMS the Change Request 13882 to avoid using an invalid ICD-10 code as the principle or primary diagnosis
- Hospice billers should also review the HOPE Active Diagnoses, comorbidities and/or coexisting conditions , and Appendix A, “Invalid Hospice Principal Diagnosis Codes” in the CMS Change Request 13882 to ensure an invalid ICD-10 code as the principle or primary diagnosis is not recorded on the patient claim form
Stay tuned for the next installment in the HOPE Assessment Tool blog series and keep your actions and momentum moving forward for the October 1, 2025 implementation.
References
The Centers for Medicare and Medicaid Services. (2025, Oct 1). Hospice outcomes and patient evaluation (HOPE) guidance manual – v1.01. https://www.cms.gov/files/document/hope-guidance-manualv101.pdf-0
The Centers for Medicare and Medicaid Services. (2025, Oct 1). Hospice item set (HIS) version(v)3.00 to hospice outcomes and patient evaluation (HOPE) v1.01 item set change table effective October 1, 2025. https://www.cms.gov/files/document/hope-item-set-change-tablehis-v300-hope-v101.pdf
The Centers for Medicare and Medicaid Services. (2025, Oct 1). HOPE guidance manual change table v1.00 to v1.01. https://www.cms.gov/files/document/hope-guidance-manualchange-tablev100-v101.pdf
The Centers for Medicare and Medicaid Services. (2025, Mar 13). Processing hospice claims – Principal diagnosis code reporting update: Medicare claims processing manual, chapter 11, sections 30.3, 40.2 & 50. https://www.cms.gov/files/document/mm13882-principal-diagnosis-code-reporting-update-hospice-and-manual-updates-section-303-402-and-50.pdf