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7500 Security Boulevard, Baltimore, MD 21244. Patients who meet the guidelines established herein are expected to have a life expectancy of six months or less if the terminal illness runs its normal course. recognition of familiar persons and faces; delusional behavior, e.g., patients may accuse their spouse of being an impostor, may talk to imaginary figures in the environment, or to their own reflection in the mirror; obsessive symptoms, e.g., person may continually repeat simple cleaning activities; anxiety agitation, and even previously nonexistent violent behavior may occur; cognitive abulia, i.e., loss of willpower because an individual cannot carry a thought long enough to determine a purposeful course of action. Stage 4 (Late Confusional)Moderate cognitive decline. The information displayed in the Tracking Sheet is pulled from the accompanying Proposed LCD and its correlating Final LCD and will be updated as new data becomes available. Note: Certain cancers with poor prognoses (e.g. of every MCD page. Another option is to use the Download button at the top right of the document view pages (for certain document types). The Palliative Performance Scale (PPS) is a modification of the Karnofsky Performance Scale intended for evaluating patients requiring palliative care. %PDF-1.4 % The 2023 edition of ICD-10-CM E43 became effective on October 1, 2022. This email will be sent from you to the ), Chronic Kidney Disease (1 and either 2, 3 or 4 should be present. However, the continuation of dialysis will significantly alter a patients prognosis, and thus potentially impact that individuals eligibility. It does not mean, however, that meeting the guideline is obligatory. Use of CDT is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). Lab testing is not required to establish hospice eligibility. Examination by a neurologist within three months of assessment for hospice is advised, both to confirm the diagnosis and to assist with prognosis. Thus a patient with metastatic small cell CA may be demonstrated to be hospice eligible with less documentation than a chronic lung disease patient. Certain cancers with poor prognoses (e.g., small cell lung cancer, brain cancer and pancreatic cancer) may be hospice eligible without fulfilling the other criteria in this section. Thus, the overall rate of decline in each patient is fairly constant and predictable, unlike many other non-cancer diseases. 0000025584 00000 n At the time of initial certification or recertification for hospice, the patient is or has been already optimally treated for heart disease, or are patients who are either not candidates for surgical procedures or who decline those procedures. Although ALS usually presents in a localized anatomical area, the location of initial presentation does not correlate with survival time. Applicable Federal Acquisition Regulation Clauses (FARS)/Department of Defense Federal Acquisition Regulation supplement (DFARS) Restrictions Apply to Government Use. End Users do not act for or on behalf of the CMS. ), Increasing pCO2 or decreasing pO2 or decreasing SaO2, Increasing calcium, creatinine or liver function studies, Progressively decreasing or increasing serum sodium or increasing serum potassium. recipient email address(es) you enter. There has been no change in coverage with this LCD revision. Ogle K, Mavis B, Wang T. Hospice and primary care physicians: attitudes, knowledge, and barriers. Generalized and cortical neurologic signs and symptoms are frequently present. Severity of malnutrition is based on phenotypic criteria only and requires one phenotypic criterion that meets the threshold of . General Guidelines:Documentation certifying terminal status must contain enough information to support terminal status upon review. The criteria refer to patients with various forms of advanced pulmonary disease who eventually follow a final common pathway for end stage pulmonary disease. May have difficulty counting from 10, both backward and sometimes forward. Reproduced with permission. Circulation. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT for resale and/or license, transferring copies of CDT to any party not bound by this agreement, creating any modified or derivative work of CDT, or making any commercial use of CDT. When performing a clinical validation review, start by confirming the presence of malnutrition and then apply validation to the level of severity. 0000037087 00000 n The criteria refer to patients with various forms of advanced pulmonary disease who eventually follow a final common pathway for end stage pulmonary disease. Unless elements in the record require explanation, such as a non-morbid diagnosis or indicators of likely greater than 6-month survival, as stated below, no extra or additional record entries should be needed to show hospice benefit eligibility.The amount and detail of documentation will differ in different situations. End User Point and Click Amendment: The American Hospital Association ("the AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. Coma Primary Criteria Patient with any 3 of the following on day three of coma: 1. 0000022017 00000 n 0000015750 00000 n of every MCD page. To submit a comment or question to CMS, please use the Feedback/Ask a Question link available at the bottom Stage2 (Forgetfulness)Very mild cognitive decline. 0000002310 00000 n The responsibility for the content of this file/product is with CMS and no endorsement by the AMA is intended or implied. E. Lamont, N. Christakis. on this web site. Please note that if you choose to continue without enabling "JavaScript" certain functionalities on this website may not be available. @7Eq p[3gXsm!t;ON-:5,lX`9^n:myuT.sf~RG}|^no\x XP\w( Also, the lack of certain documentation elements such as a tissue diagnosis for cancer will not create non-eligibility for the hospice benefit, but does necessitate other supportive documentation.Documentation submitted may include information from periods of time that fall outside the billing period currently under review. Copyright © 2022, the American Hospital Association, Chicago, Illinois. Mild to moderate anxiety accompanies symptoms. The Tracking Sheet provides key details about the Proposed LCD, including a summary of the issue, who requested the new/updated policy, links to key documents, important process-related dates, who to contact with questions about the policy, and the history of previous policy considerations. Almost always recall their own name. 2001;104:2996-3007. Studies enrolling individuals with planned admissions (e.g. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. Proposed LCD document IDs begin with the letters "DL" (e.g., DL12345). ), Patients will be considered to be in the terminal stage of their illness (life expectancy of six months or less) if they meet the following criteria. 0000011939 00000 n Note, however, paragraph 3 of 'General Indications' under "Indications and Limitations of Coverage and/or Medical Necessity" regarding patients who improve or stabilize.Documentation should paint a picture for the reviewer to clearly see why the patient is appropriate for hospice care and the level of care provided, i.e., routine home, continuous home, inpatient respite, or general inpatient. The former can be managed by artificial ventilation, and the latter by gastrostomy or other artificial feeding, unless the patient has recurrent aspiration pneumonia. CPT codes, descriptions and other data only are copyright 2022 American Medical Association. 2004;7(1):47-53. resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; The use of the New York heart association's classification of cardiovascular disease as part of the patient's complete problem list. You, your employees and agents are authorized to use CPT only as agreed upon with the AMA internally within your organization within the United States for the sole use by yourself, employees and agents. recommending their use. Neither the United States Government nor its employees represent that use of All Rights Reserved (or such other date of publication of CPT). On the other hand, patients in the terminal stage of their illness who originally qualify for the Medicare hospice benefit but stabilize or improve while receiving hospice care, yet have a reasonable expectation of continued decline for a life expectancy of less than six months, remain eligible for hospice care.IndicationsA patient will be considered to have a life expectancy of six months or less if he/she meets the non-disease specific "Decline in clinical status" guidelines described in Part I. Alternatively, the baseline non-disease specific guidelines described in Part II plus the applicable disease specific guidelines listed in Part III will establish the necessary expectancy.Part I. 0000039481 00000 n The responsibility for the content of this file/product is with CMS and no endorsement by the AMA is intended or implied. Non-disease specific baseline guidelines (both A and B should be met), Part III. You can use your browser's Print function (Ctrl-P on a PC or Command-P on a Mac) to view a print preview and then select PDF as the output. Instructions for enabling "JavaScript" can be found here. The AMA assumes no liability for data contained or not contained herein. Some patients may not meet these guidelines, yet still have a life expectancy of six months or less. Nausea/vomiting poorly responsive to treatment. 844-4CHILDRENS (844-424-4537) 844-424-4537; Patient Login (MyChart . Other clinical variables not on this list may support a six-month or less life expectancy. Since determination of decline presumes assessment of the patients status over time, it is essential that both baseline and follow-up determinations be reported where appropriate. First, make sure the malnutrition meets the definition of a secondary diagnosisi.e., is there evaluation, monitoring, treatment, increased nursing care and/or increased length of stay. Pyelonephritis or other upper urinary tract infection; Inability to maintain sufficient fluid and calorie intake with 10% weight loss during the previous six months or serum albumin <2.5 gm/dl. "JavaScript" disabled. Language quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. Medicare coverage of hospice depends on a physicians certification that an individuals prognosis is a life expectancy of six months or less if the terminal illness runs its normal course. P rint Checklist: Documenting malnutrition (E41 and E43) This checklist is intended to provide healthcare providers with a reference for use when responding to medical documentation requests for services rendered and hospital admissions to treat malnutrition. Before an LCD becomes final, the MAC publishes Proposed LCDs, which include a public comment period. Flattening of affect and withdrawal from challenging situations occur. They may be incorporated by specific reference as part (or all) of the indication for recertification. 0000008839 00000 n Cachexia should have been listed as i. and not beside Albumin with ii, this has been corected. The amendment clarified that the certification is based on a clinical judgment regarding the usual course of a terminal illness, and recognizes the fact that making medical prognostications of life expectancy is not always exact. such information, product, or processes will not infringe on privately owned rights. Therefore, multiple clinical parameters are required to judge the progression of ALS. Patients with dementia or Alzheimer's are eligible for hospice care when they show all of the following characteristics: 1. Neither the United States Government nor its employees represent that use of ; Obstructive hydrocephalus in patient who declines, or is not a candidate for, ventriculoperitoneal shunt. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material. 2001;134:1097-1143.McCluskey L, Houseman G. Medicare hospice referral criteria for patients with amyotrophic lateral sclerosis: a need for improvement. Our audit covered $3.4 billion in Medicare payments for 224,175 claims with a discharge date in fiscal year (FY) 2016 or 2017 that contained a severe malnutrition diagnosis code and for which removing the diagnosis code changed the diagnosis-related group (DRG). 708 0 obj <>stream The AMA does not directly or indirectly practice medicine or dispense medical services. License to use CPT for any use not authorized herein must be obtained through the AMA, CPT Intellectual Property Services, AMA Plaza 330 N. Wabash Ave., Suite 39300, Chicago, IL 60611-5885. While not necessarily a contraindication to Hospice Care, the decision to institute either artificial ventilation or artificial feeding will significantly alter six-month prognosis. Goal: 90%. Frequently no deficit in the following areas: Inability to perform complex tasks. Increasing emergency room visits, hospitalizations, or physicians visits related to hospice primary diagnosis, Progressive decline in Functional Assessment Staging (FAST) for dementia (from 7A on the FAST), Progression to dependence on assistance with additional activities of daily living (See Part II, Section 2), Progressive stage 3-4 pressure ulcers in spite of optimal care. These should be documented in the clinical record.These changes in clinical variables apply to patients whose decline is not considered to be reversible. Such patients have no identified structural or functional abnormalities of the pericardium, myocardium, or cardiac valves and have never shown signs or symptoms of HF.Example:Systemic hypertension; coronary artery disease; diabetes mellitus; history of cardiotoxic drug therapy or alcohol abuse; personal history of rheumatic fever; family history of cardiomyopathy.Stage BPatients who have developed structural heart disease that is strongly associated with the development of HF but who have never show signs or symptoms of HF.Example:Left ventricular hypertrophy or fibrosis; left ventricular dilatation or hypocontractility; asymptomatic valvular heart disease; previous myocardial infarction.Stage CPatients who have current or prior symptoms of HF associated with underlying structural heart disease.Example:Dyspnea or fatigue due to left ventricular systolic dysfunction; asymptomatic patients who are undergoing treatment for prior symptoms of HF.Stage DPatients with advanced structural heart disease and marked symptoms of HF at rest despite maximal medical therapy and who require specialized interventions.Example:Patients who are frequently hospitalized for HF or cannot be safely discharged from the hospital; patients in the hospital awaiting heart transplantation; patients at home receiving continuous intravenous support for symptom relief or being supported with a mechanical circulatory assist device; patients in a hospice setting for management of HF.Karnofsky Performance Scale (KPS)The Karnofsky Performance Scale Index allows patients to be classified as to their functional impairment. Clear-cut deficit on careful clinical interview. Please note that if you choose to continue without enabling "JavaScript" certain functionalities on this website may not be available. This section is specific for Alzheimers disease and Related Disorders, and is not appropriate for other types of dementia. Physicians and hospice care: attitudes, knowledge, and referrals. )Documentation should support the level of care being provided to the patient during the time period under review, i.e. 0000039400 00000 n This policy describes guidelines to be used by Home Health & Hospice (HH&H) MAC in reviewing hospice claims and by hospice providers to determine eligibility of beneficiaries for hospice benefits. Appropriate concern regarding symptoms. Some patients may not meet these guidelines, yet still have a life expectancy of six months or less. Documentation of the applicable criteria listed under the Indications section of this policy would meet this requirement. In end-state ALS, two factors are critical in determining prognosis: ability to breathe, and to a lesser extent ability to swallow. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. Examination by a neurologist within three months of assessment for hospice is advised, both to confirm the diagnosis and to assist with prognosis. Extent and determinants of error in doctors prognoses in terminally ill patients: prospective cohort study. 2003;20: 41-51.Ogle K, Mavis B, Wang T. Physicians and hospice care: attitudes, knowledge and referrals. Christakis N, Lamont E. Extent and determinants of error in doctors prognoses in terminally ill patients: prospective cohort study. All billing and coding information was previously moved to the related Billing and Coding Article, A52830. Critically impaired breathing capacity as demonstrated by all the following characteristics occurring within the 12 months preceding initial hospice certification: Vital capacity (VC) less than 30% of normal (if available); Patient declines mechanical ventilation; external ventilation used for comfort measures only. Baseline data may be established on admission to hospice or by using existing information from records. CMS and its products and services are not endorsed by the AHA or any of its affiliates. Applicable FARS\DFARS Restrictions Apply to Government Use. 0000011336 00000 n The American Hospital Association ("the AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. As used herein, "you" and "your" refer to you and any organization on behalf of which you are acting. Although guidelines applicable to certain disease categories are included, this LCD is applicable to all hospice patients. Subjective complaints of memory deficit, most frequently in the following area: No objective evidence of memory deficit on clinical interview. Muscle wasting with reduced strength and endurance; Continued active alcoholism (> 80 gm ethanol/day); Hepatitis C refractory to interferon treatment. Progression of disease as documented by worsening clinical status, symptoms, signs and laboratory results. 0000037443 00000 n Factors from 3 will add supporting documentation. Requires occasional assistance, but is able to care for most of his personal needs. 646 0 obj <> endobj 0000015606 00000 n Physiologic impairment of functional status as demonstrated by: Karnofsky Performance Status (KPS) or Palliative Performance Score (PPS) < 70%. Applicable Federal Acquisition Regulation Clauses (FARS)/Department of Defense Federal Acquisition Regulation supplement (DFARS) Restrictions Apply to Government Use. and the State Children's Health Insurance Programs, contracts with certain organizations to assist in the administration of the 1999;22(6):385-90.Lamont E, Christakis N. Prognostic disclosure to patients with cancer near the end of life. Patients are considered eligible for Hospice care if they do not elect tracheostomy and invasive ventilation and display evidence of critically impaired respiratory function (with or without use of NIPPV) and / or severe nutritional insufficiency (with or without use of a gastrostomy tube). To capture use of hypocaloric PN dosing. Decline in Karnofsky Performance Status (KPS ) or Palliative Performance Score (PPS) due to progression of disease. Hepatic encephalopathy, refractory to treatment, or patient non-compliant; Recurrent variceal bleeding, despite intensive therapy. 0000040858 00000 n ge"^WOgr |___W+ tpIht=hozGC8 The 2023 edition of ICD-10-CM E46 became effective on October 1, 2022. The criteria refer to patients with various forms of advanced pulmonary disease who eventually follow a final common pathway for end stage pulmonary disease. MACs develop an LCD when there is no national coverage determination (NCD) (e.g., when an item or service is new) or when there is a need to further define an NCD for the specific jurisdiction. This LCD outlines coverage for hospice as indicated in the coverage and indications section. It is intended to be used to identify any Medicare beneficiary whose current clinical status and anticipated progression of disease is more likely than not to result in a life expectancy of six months or less. Comatose patients with any 3 of the following on day three of coma: Documentation of medical complications, in the context of progressive clinical decline, within the previous 12 months, which support a terminal prognosis: Documentation of diagnostic imaging factors which support poor prognosis after stroke include: Infratentorial: greater than or equal to 20 ml. To submit a comment or question to CMS, please use the Feedback/Ask a Question link available at the bottom Patients will be considered to be in the terminal stage of heart disease (life expectancy of six months or less) if they meet the following criteria. Normal no complaints; no evidence of disease. Progressive malnutrition, muscle wasting with dec. strength, ongoing alcoholism (>80 gm . No subjective complaints of memory deficit. Progressive inanition is documented by several measures such as 10% body weight loss, decreased albumin, and dysphagia leading to aspiration, among others. These changes in clinical variables apply to patients whose decline is not considered to be reversible. Such patients can be re-enrolled for a new benefit period when a decline in their clinical status is such that their life expectancy is again six months or less. 0000159154 00000 n (1 and 2 should be present, factors from 3 will lend supporting documentation. K. Ogle, B. Mavis, G. Wyatt. The Centers for Medicare & Medicaid Services (CMS), the federal agency responsible for administration of the Medicare, Medicaid A52830 - Billing and Coding: Hospice: Determining Terminal Status. Progressive loss of abilities to walk, sit up, smile, and hold head up. (1 and 2 should be present; factors from 3 will lend supporting documentation. The New York Heart Association (NYHA) Functional Classification provides a simple way of classifying heart disease (originally cardiac failure). Surface area of involvement of hemorrhage greater than or equal to 30% of cerebrum; Midline shift greater than or equal to 1.5 cm. They are examples of findings that generally connote a poor prognosis. The two main criteria are the American Society for Parenteral and Enteral Nutrition (ASPEN) and the Global Leadership Initiative on Malnutrition (GLIM). Patients should have had one of the following within the past 12 months: Inability to maintain sufficient fluid and calorie intake with 10% weight loss during the previous six months or serum albumin < 2.5 gm/dl. Clin Cardiol. 0000039330 00000 n No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be