Organizations who contract with CMS acknowledge that they may have a commercial CDT license with the ADA, and that use of CDT codes as permitted herein for the administration of CMS programs does not extend to any other programs or services the organization may administer and royalties dues for the use of the CDT codes are governed by their commercial license. Unspecified severe protein-calorie malnutrition. Journal of Palliative Medicine. 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. If you are acting on behalf of an organization, you represent that you are authorized to act on behalf of such organization and that your acceptance of the terms of this agreement creates a legally enforceable obligation of the organization. without the written consent of the AHA. Protein Calorie Malnutrition Hospice Criteria. and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only Pulmonary Disease. Karnofsky Performance Status (KPS) or Palliative Performance Scale (PPS) of < 40% . Examination by a neurologist within three months of assessment for hospice is advised, both to confirm the diagnosis and to assist with prognosis. GENERAL INDICATIONS: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. Also, you can decide how often you want to get updates. The Tracking Sheet modal can be closed and re-opened when viewing a Proposed LCD. In end-state ALS, two factors are critical in determining prognosis: ability to breathe, and to a lesser extent ability to swallow. End User License Agreement: 1993:109.Friedman B, Harwood S. Barriers and enablers to hospice referrals: an expert overview. preparation of this material, or the analysis of information provided in the material. Factors from 5 will lend supporting documentation. If you are experiencing any technical issues related to the search, selecting the 'OK' button to reset the search data should resolve your issues. 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. History of increasing ER visits, hospitalizations, or physician visits related to the hospice primary diagnosis prior to election of the hospice benefit. The page could not be loaded. 0000008839 00000 n The AMA does not directly or indirectly practice medicine or dispense medical services. 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. 2001;134:1097-1143.McCluskey L, Houseman G. Medicare hospice referral criteria for patients with amyotrophic lateral sclerosis: a need for improvement. Cancer. Unable to work; able to live at home and care for most personal needs; varying amount of assistance needed. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. Generally unaware of their surroundings, the year, the season, etc. See Part III for disease specific guidelines to be used with these baseline guidelines. Medicare program. or to place. In no event shall CMS be liable for direct, indirect, This bibliography presents those sources that were obtained during the development of this policy. Other clinical variables not on this list may support a six-month or less life expectancy. and the State Children's Health Insurance Programs, contracts with certain organizations to assist in the administration of the At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. All Rights Reserved. CEA, PSA); Progressively decreasing or increasing serum sodium or increasing serum potassium. xref 0000009983 00000 n These should be documented in the clinical record. Documentation of the following factors will support but is not required to establish eligibility for hospice care: Treatment resistant symptomatic supraventricular or ventricular arrhythmias; History of cardiac arrest or resuscitation; CD4+ Count 100,000 copies/ml, plus one of the following: Untreated, or persistent despite treatment, wasting (loss of at least 10% lean body mass); Mycobacterium avium complex (MAC) bacteremia, untreated, unresponsive to treatment, or treatment refused; Progressive multifocal leukoencephalopathy; Systemic lymphoma, with advanced HIV disease and partial response to chemotherapy; Visceral Kaposis sarcoma unresponsive to therapy; Renal failure in the absence of dialysis; Decreased performance status, as measured by the Karnofsky Performance Status (KPS) scale, of 50%. The patient is classified as New York Heart Association (NYHA) Class IV and may have significant symptoms of heart failure or angina at rest. recommending their use. Progression from an earlier stage of disease to metastatic disease with either:1. a continued decline in spite of therapy2. As with any other condition, an individual with renal disease is eligible for the Hospice benefit if that individual has a prognosis of six months or less, if the illness runs its normal course. 0000037955 00000 n Frequently some disorientation to time (date, day of week, season, etc.) 2000;320:469-472.Crooks V, Waller S, Smith T, Hahn TJ. They are listed in order of their likelihood to predict poor survival, the most predictive first and the least predictive last. Some patients decline rapidly and die quickly; others progress more slowly. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. Therefore, multiple clinical parameters are required to judge the progression of ALS. 1991;155:384-387.Reisberg B. ElderCare online. 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. Will require some assistance with activities of daily living, e.g., may become incontinent, will require travel assistance but occasionally will display ability to familiar locations. Note: Certain cancers with poor prognoses (e.g. Percentage of patients receiving PN in the ICU who receive 80% of estimated energy requirements or 20 kcals/kg/day and a minimum of 1.2 g protein/kg/day. Patients will be considered to be in the terminal stage of pulmonary disease (life expectancy of six months or less) if they meet the following criteria. (Class IV patients with heart disease have an inability to carry on any physical activity without discomfort. 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. %PDF-1.4 % Although guidelines applicable to certain disease categories are included, this LCD is applicable to all hospice patients. Progressive inanition is documented by several measures such as 10% body weight loss, decreased albumin, and dysphagia leading to aspiration, among others. 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. You can use the Contents side panel to help navigate the various sections. Similarly, . Hospice Eligibility Criteria Patient has a terminal illness with a life . 0000017107 00000 n Speech ability declines to about a half-dozen intelligible words. 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.Clinical variables with general applicability without regard to diagnosis, as well as clinical variables applicable to a limited number of specific diagnoses, are provided. 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. CPT codes, descriptions and other data only are copyright 2022 American Medical Association. 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. 0000017875 00000 n Use of CDT is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). J Clin Oncology. When performing a clinical validation review, start by confirming the presence of malnutrition and then apply validation to the level of severity. Denial begins to become manifest in patient. At least two of the six characteristics are needed for the diagnosis of malnutrition. 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. 1984;2:187-193. Some patients may not meet these guidelines, yet still have a life expectancy of six months or less. 0000012920 00000 n 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. Hospice and primary care physicians: attitudes, knowledge, and barriers. Patient declines further disease directed therapy. Made a technical update to this LCD to remove the empty Coding Information fields. B. 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. The Global Malnutrition Composite Score (GMCS) electronic clinical quality measure is comprised of four components reflecting inpatient malnutrition identification and care. Hepatic encephalopathy, refractory to treatment, or patient non-compliant; Recurrent variceal bleeding, despite intensive therapy. (This value may be obtained from recent [within 3 months] hospital records.). SPECIFIC INDICATIONS:A 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 the appendix will establish the necessary expectancy. ; Obstructive hydrocephalus in patient who declines, or is not a candidate for, ventriculoperitoneal shunt. 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. Another option is to use the Download button at the top right of the document view pages (for certain document types). Progressive stage 3-4 pressure ulcers in spite of optimal care. )Documentation should support the level of care being provided to the patient during the time period under review, i.e. This email will be sent from you to the Patients who have current or prior symptoms of HF associated with underlying structural heart disease. Decline in clinical status guidelinesPatients will be considered to have a life expectancy of six months or less if there is documented evidence of decline in clinical status based on the guidelines listed below. Please visit the. <]/Prev 527120/XRefStm 1970>> OR Hypercapnia, as evidenced by pCO2 50 mmHg. As each patient is unique, there are patients for whom a particular guideline does not match. 0000005794 00000 n 0000011939 00000 n Inability to maintain sufficient fluid and calorie intake with 10% weight loss during the previous six months or serum albumin <2.5 gm/dl . 0000002894 00000 n preparation of this material, or the analysis of information provided in the material. Surface area of involvement of hemorrhage 30% of cerebrum; Obstructive hydrocephalus in patient who declines, or is not a candidate for, ventriculoperitoneal shunt. 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. Inability to maintain hydration and caloric intake with one of the following: Weight loss > 10% in the last 6 months or > 7.5% in the last 3 months; Current history of pulmonary aspiration not responsive to speech language pathology intervention; Sequential calorie counts documenting inadequate caloric/fluid intake; Dysphagia severe enough to prevent patient from continuing fluids/foods necessary to sustain life and patient does not receive artificial nutrition and hydration. The patient is not seeking dialysis or renal transplant, or is discontinuing dialysis; As with any other condition, an individual with renal disease is eligible for the Hospice benefit if that individual has a prognosis of six months or less, if the illness runs its normal course. special, incidental, or consequential damages arising out of the use of such information, product, or process. THE UNITED STATES GOVERNMENT AND ITS EMPLOYEES ARE NOT LIABLE FOR ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN 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. While not necessarily a contraindication to Hospice Care, the decision to institute either artificial ventilation or artificial feeding will significantly alter six-month prognosis. British Medical Journal. The former can be managed by artificial ventilation, and the latter by gastrostomy or other artificial feeding, unless the patient has recurrent aspiration pneumonia. + CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE.
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