A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. Documentation of the following factors will support eligibility for hospice care: Chronic persistent diarrhea for one year; Absence of or resistance to effective antiretroviral, chemotherapeutic and prophylactic drug therapy related specifically to HIV disease; Congestive heart failure, symptomatic at rest; Prothrombin time prolonged more than 5 seconds over control, or International Normalized Ratio (INR) > 1.5; End stage liver disease is present and the patient shows at least one of the following: Ascites, refractory to treatment or patient non-compliant; Hepatorenal syndrome (elevated creatinine and BUN with oliguria (< 400 ml/day) and urine sodium concentration < 10 mEq/l); Hepatic encephalopathy, refractory to treatment, or patient non-compliant; Recurrent variceal bleeding, despite intensive therapy. endstream endobj 707 0 obj <>/Filter/FlateDecode/Index[47 599]/Length 42/Size 646/Type/XRef/W[1 1 1]>>stream Note: Certain cancers with poor prognoses (e.g. Recurrent or intractable infections such as pneumonia, sepsis or upper urinary tract. 0000014780 00000 n Barriers and enablers to hospice referrals: an expert overview. Circulation. 0000005335 00000 n These guidelines are to be used in conjunction with the Non-disease specific baseline guidelines described in Part II. Malnutrition in Hospitalized Adults | Effective Health Care (EHC) Program Disease-specific guidelines for hospice - UpToDate Large anterior infarcts with both cortical and subcortical involvement. This page displays your requested Local Coverage Determination (LCD). E46 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. Requires assistance dressing, bathing, and toileting. Appropriate concern regarding symptoms. You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. Made a technical update to this LCD to remove the empty Coding Information fields. been made to provide accurate and complete information, CMS does not guarantee that there are no errors in the information displayed It places patients in one of four categories, based on how much they are limited during physical activity:Class I: patients with no limitation of activities; they suffer no symptoms from ordinary activities.Class II: patients with slight, mild limitation of activity; they are comfortable with rest or with mild exertion.Class III: patients with marked limitation of activity; they are comfortable only at rest.Class IV: patients who should be at complete rest, confined to bed or chair; any physical activity brings on discomfort and symptoms occur at rest.Palliative Performance ScaleThe Palliative Performance Scale (PPS) is a modification of the Karnofsky Performance Scale intended for evaluating patients requiring palliative care. small cell lung cancer, brain cancer and pancreatic cancer) may be hospice eligible without fulfilling the other criteria in this section.Section II: Non-Cancer DiagnosesA. 2002;5:73-84.Hollen PJ, Gralla RJ, Dris MG, et al. National Government Services is not responsible for the continuing viability of Web site addresses listed below. Symptoms of heart failure or of the anginal syndrome may be present even at rest. Recertification for hospice care requires the same clinical standards be met as for initial certification, but they need not be reiterated. ]6o?7#qij]e]#mvb:~=y1\N(QhnX- }%h=#8At#ZRUpJK$\v&$&Np\KOI&'=%Oxu}j.bJBmv;]wy'.p|Wst]M3 \;y^zLGazW@ZzLgZ\$f29o"T=c(%/&Kp:,j{L Fu G Nutritional supplementation is one of the most important interventions in patients with failure to thrive. CPT codes, descriptions and other data only are copyright 2022 American Medical Association. 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. Progression from an earlier stage of disease to metastatic disease with either:1. a continued decline in spite of therapy2. Hospice Eligibility Guidelines - Agape Care Group Georgia It was developed in British Columbia, Canada. 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. Part II. The population for key question 3 will only include patients with a diagnosis of protein-energy malnutrition. Federal government websites often end in .gov or .mil. N. Christakis, E. Lamont. HMn1>.`Ax! Persons at this stage retain knowledge of many major facts regarding themselves and others. 0000012375 00000 n 0000037087 00000 n Baseline data may be established on admission to hospice or by using existing information from records. 0000029167 00000 n (Documentation of serial decrease of FEV1>40 ml/year is objective evidence for disease progression, but is not necessary to obtain. Evaluating cancer patients for rehabilitation potential. While these characteristics are assessed along a continuum, rather than as discrete variables, they are useful in formulating and documenting a diagnosis of malnutrition. Extent and determinants of error in doctors prognoses in terminally ill patients: prospective cohort study. J Palliative Medicine. While not necessarily a contraindication to Hospice Care, the decision to institute either artificial ventilation or artificial feeding will significantly alter six-month prognosis. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. An official website of the United States government. small cell lung cancer, brain cancer and pancreatic cancer) may be hospice eligible without fulfilling the other criteria in this section. However, some are clearly more predictive of a poor prognosis than others; significant ongoing weight loss is a strong predictor, while decreased functional status is less so. 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. Please enable "JavaScript" and revisit this page or proceed with browsing CMS.gov with No fee schedules, basic unit, relative values or related listings are included in CPT. or to place. Significant congestive heart failure may be documented by an ejection fraction of less than or equal to 20%, but is not required if not already available. 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. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely. Documentation of 3, 4, and 5, will lend supporting documentation. This email will be sent from you to the not endorsed by the AHA or any of its affiliates. Dysphagia severe enough to prevent the patient from receiving food and fluids necessary to sustain life, in a patient who declines or does not receive artificial nutrition and hydration. Part I. Thus a patient with metastatic small cell CA may be demonstrated to be hospice eligible with less documentation than a chronic lung disease patient. The AMA assumes no liability for data contained or not contained herein. Before sharing sensitive information, make sure you're on a federal government site. 3p=3t8@g3`PWYGQGYGQGYGQGYGQGo_e~kWB[({W}cw}QnoooooERa^*H78mQ_/.K 0 The brain appears to no longer be able to tell the body what to do. Documentation of 3, 4, and 5, will lend supporting documentation. They are listed in order of their likelihood to predict poor survival, the most predictive first and the least predictive last. An official website of the United States government. These materials contain Current Dental Terminology (CDTTM), copyright© 2022 American Dental Association (ADA). Stage 3 (Early Confusional)Mild cognitive decline. Applicable FARS/HHSARS apply. If you do not agree with all terms and conditions set forth herein, click below on the button labeled "I do not accept" and exit from this computer screen. If you do not agree with all terms and conditions set forth herein, click below on the button labeled "I do not accept" and exit from this computer screen. As used herein, "you" and "your" refer to you and any organization on behalf of which you are acting. Hospice Admissions Guidelines for Dementia & Alzheimer's - VITAS You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. The use of the Karnofsky Performance Scale in determining outcomes and risk in geriatric outpatients. Patients will be considered to be in the terminal stages of stroke or coma (life expectancy of six months or less) if they meet the following criteria: Patients at high risk of developing HF because of the presence of conditions that are strongly associated with the development of HF. These should be documented in the clinical record. Clear-cut deficit on careful clinical interview. 0 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. 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. ), HIV DiseasePatients 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. Denial is dominant defense mechanism. However, the continuation of dialysis will significantly alter a patients prognosis, and thus potentially impact that individuals eligibility. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials. J Palliative Medicine 2002; 5; 73-84. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. K. Ogle, B. Mavis, G. Wyatt. H. Stroke & ComaPatients will be considered to be in the terminal stage of stroke or coma (life expectancy of six months or less) if they meet the following criteria.Stroke: Documentation of diagnostic imaging factors which support poor prognosis after stroke include: Coma (any etiology): Comatose patients with any 3 of the following on day three of coma: Documentation of the following factors will support eligibility for hospice care: Documentation of medical complications, in the context of progressive clinical decline, within the previous 12 months, which support a terminal prognosis: This policy consolidates, simplifies and supercedes the several current hospice local medical review policies on determining terminal status previously implemented by this contractor whose references are incorporated herewith. Documentation of the applicable criteria listed under the Indications section of this policy would meet this requirement. Non-disease specific baseline guidelines (both of these should be met), See appendix for disease specific guidelines to be used with these (Part II) baseline guidelines. Neither the United States Government nor its employees represent that use of Muscle wasting with reduced strength and endurance; Continued active alcoholism (>80 gm ethanol/day); Hepatitis C refractory to interferon treatment. Non-disease specific baseline guidelines (both A and B should be met), Part III. A Local Coverage Determination (LCD) is a decision made by a Medicare Administrative Contractor (MAC) on whether a particular service or item is reasonable and necessary, and therefore covered by Medicare within the specific jurisdiction that the MAC oversees. Malnutrition, Obesity and BMI : Medical Coding Guidelines This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy. The score can help determine which patients can be managed in the home and which should be admitted to a hospice unit. Patients will be considered to be in the terminal stage of renal disease (life expectancy of six months or less) if they meet the following criteria. No objective deficits in employment or social situations. Part II. 0000038836 00000 n They would use ICD-10-CM code E42 to report severe protein-calorie malnutrition with signs of both kwashiorkor and marasmus. Stage2 (Forgetfulness)Very mild cognitive decline. Symptoms of heart failure or of the anginal syndrome may be present even at rest. (Optimally treated means that patients who are not on vasodilators have a medical reason for refusing these drugs, e.g., hypotension or renal disease.). These are quite variable and include: Stage 7 (Late Dementia) Very severe cognitive decline. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely. Your MCD session is currently set to expire in 5 minutes due to inactivity. Unable to care for self; requires equivalent of institutional or hospital care; disease may be progressing rapidly. It was developed in British Columbia, Canada. ): G. Renal DiseasePatients will be considered to be in the terminal stage of renal disease (life expectancy of six months or less) if they meet the following criteria.Acute renal failure: (1 and either 2 or 3 should be present. 2001;104:2996-3007. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). No specific number of variables must be met, but fewer of those listed first (more predictive) and more of those listed last (least predictive) would be expected to predict longevity of six months or less. 646 63 At the New York University Medical Center's Aging and Dementia Research Center, Barry Reisberg, MD and colleagues have developed the Functional Assessment Staging (FAST) scale, which allows professionals and caregivers to chart the decline of people with Alzheimer's disease. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. 0000017107 00000 n This Agreement will terminate upon notice if you violate its terms. No memory deficit evident on clinical interviews. THE INFORMATION, PRODUCT, OR PROCESSES DISCLOSED HEREIN. See 1869(f)(1)(A)(i) of the Social Security Act. Lab testing is not required to establish hospice eligibility. Learn more about the causes and symptoms. 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. Coverage for these patients may be approved if documentation of clinical factors supporting a less than 6-month life expectancy not included in these guidelines is provided. SERUM PROTEIN and the State Children's Health Insurance Programs, contracts with certain organizations to assist in the administration of the and the State Children's Health Insurance Programs, contracts with certain organizations to assist in the administration of the 1993:109.Friedman B, Harwood S. Barriers and enablers to hospice referrals: an expert overview. CEA, PSA); Progressively decreasing or increasing serum sodium or increasing serum potassium. 0000060832 00000 n However, documentation expectations should comport with normal clinical documentation practices. patients with slight, mild limitation of activity; they are comfortable with rest or with mild exertion. Revision Explanation:Converted policy into new policy template that no longer includes coding section based on CR 10901. Factors from 3 will add supporting documentation. For this reason, the history of the rate of progression in individual patients is important to obtain to predict prognosis. End User License Agreement: Some patients may not meet these guidelines, yet still have a life expectancy of 6 months or less. startxref Subject to the terms and conditions contained in this Agreement, you, your employees and agents are authorized to use CDT only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Progression of disease as documented by worsening clinical status, symptoms, signs and laboratory results. Flattening of affect and withdrawal from challenging situations occur. 0000001970 00000 n Applications are available at the American Dental Association web site. Inability to maintain hydration and caloric intake with 1 of the following: weight loss >10% in the last 6 months or >7. . preparation of this material, or the analysis of information provided in the material. Instructions for enabling "JavaScript" can be found here. 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. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. Hence, it was concluded that albumin cannot be reliably used as a marker for diagnosing protein-calorie malnutrition . - Social Security Act, Sections 1102, 1812 (a)(4) and (d); 1813 (a) (4); 1814 (a)(7) and (I); 1862 (a)(1), (6), and (9); 1861 (dd), 1871- 42 CFR Part 418- CMS Publication 100-02, Medicare Benefit Policy, Chapter 9.- CMS Publication 100-04, Medicare Claims Processing, Chapter 30. The baseline guidelines do not independently qualify a patient for hospice coverage. CPT codes, descriptions and other data only are copyright 2022 American Medical Association. A hospice needs to be certain that the physician's clinical judgment can be supported by clinical information and other documentation that provide a basis for the certification of 6 months or less if the illness runs its normal course. An asterisk (*) indicates a 0000039400 00000 n LCD document IDs begin with the letter "L" (e.g., L12345). AJ Hospice & Palliative Care. These situations are obvious. 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. Almost always recall their own name. All Rights Reserved (or such other date of publication of CPT). The baseline guidelines do not independently qualify a patient for hospice coverage.Note: The word should in the disease specific guidelines means that on medical review the guideline so identified will be given great weight in making a coverage determination. Current Dental Terminology © 2022 American Dental Association. rVjh)aV 5%TO)i='@]Rx\EM~{m.3:t.UPu]*;bSj7U 0%q3- RJT40(?9O1UsFS3*CR|lf[`s40Q\r*u22,!5jc-+z ]o s The views and/or positions presented in the material do not necessarily represent the views of the AHA. 0000040080 00000 n accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the See Part III for disease specific guidelines to be used with these baseline guidelines. MACs are Medicare contractors that develop LCDs and process Medicare claims. Protein-Energy Malnutrition / diagnosis Serum Albumin / analysis Substances Amino Acids . 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. Generally unaware of their surroundings, the year, the season, etc. LCD - Hospice - Determining Terminal Status (L33393) End Users do not act for or on behalf of the CMS. 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. The AMA does not directly or indirectly practice medicine or dispense medical services. 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. C. Heart Disease. authorized with an express license from the American Hospital Association. 2000;320:469-472.Crooks V, Waller S, Smith T, Hahn TJ. Subjective complaints of memory deficit, most frequently in the following area: No objective evidence of memory deficit on clinical interview. Healthcare providers retain responsibility to submit complete and accurate. Dr Reisberg has also shown that the decline typical of Alzheimer's disease is the flip side of normal skill acquisition by infants, children, and young adults: Available from ElderCare Online http://www.ec-online.net/ Barry Reisberg, MD 1984. 01/11/2021: At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. of every MCD page. (1 and either 2, 3 or 4 should be present. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or CMS and its products and services are Please note that if you choose to continue without enabling "JavaScript" certain functionalities on this website may not be available. Left ventricular hypertrophy or fibrosis; left ventricular dilatation or hypocontractility; asymptomatic valvular heart disease; previous myocardial infarction. Annals of Internal Medicine. PDF Tools and Guidelines for Determining Eligibility for Hospice - Providence Note: 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.Non-Cancer DiagnosesAmyotrophic Lateral SclerosisGeneral Considerations: 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).Critically impaired respiratory function is as defined by: Severe nutritional insufficiency is defined as:Dysphagia with progressive weight loss of at least five percent of body weight with or without election for gastrostomy tube insertion.These revised criteria rely less on the measured FVC, and as such reflect the reality that not all patients with ALS can or will undertake regular pulmonary function tests.Dementia due to Alzheimers Disease and Related DisordersPatients will be considered to be in the terminal stage of dementia (life expectancy of six months or less) if they meet the following criteria. Denial begins to become manifest in patient. End User Point and Click Amendment:
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