The views and/or positions 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). Earliest clear-cut deficits. 0000005794 00000 n Note that two of the disease specific guidelines (HIV Disease, Stroke and Coma) establish a lower qualifying KPS or PPS. Patients will be considered to be in the terminal stages of stroke or coma (life expectancy of 6 months or less) if they meet the following criteria: Stroke: KPS or Palliative Performance Scale of 40% or less. To capture use of hypocaloric PN dosing. The scope of this license is determined by the AMA, the copyright holder. 0000038836 00000 n 0000039481 00000 n recipient email address(es) you enter. CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. The Global Malnutrition Composite Score (GMCS) electronic clinical quality measure is comprised of four components reflecting inpatient malnutrition identification and care. Inability to maintain sufficient fluid and calorie intake with 10% weight loss during the previous six months or serum albumin <2.5 gm/dl . 0000011939 00000 n on this web site. Weight loss not due to reversible causes such as depression or use of diuretics, Decreasing anthropomorphic measurements (mid-arm circumference, abdominal girth), not due to reversible causes such as depression or use of diuretics. (Documentation of serial decrease of FEV1>40 ml/year is objective evidence for disease progression, but is not necessary to obtain. Factors from 4 will lend supporting documentation. This page displays your requested Local Coverage Determination (LCD). This can be used to compare effectiveness of different therapies and to assess the prognosis in individual patients. Requires assistance dressing, bathing, and toileting. http://www.ed-online.net\. 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. Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by clicking below on the button labeled "I Accept". 0000004710 00000 n Cancer. without the written consent of the AHA. Another option is to use the Download button at the top right of the document view pages (for certain document types). Decline in Karnofsky Performance Status (KPS ) or Palliative Performance Score (PPS) due to progression of disease. 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. The baseline guidelines do not independently qualify a patient for hospice coverage. In critically ill patients, these alterations can. 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. ), 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. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This email will be sent from you to the You acknowledge that the ADA holds all copyright, trademark and other rights in CDT. HMn1>.`Ax! 4 Methodologies to Determine Hospice Eligibility Meets Local Coverage Determinations (LCD) Meets most LCD guidelines and documented decline Meets most LCD guidelines and additional co-morbidities Physician's clinical judgment Guidelines & Indicators General Guidelines Non-specific Disease Guidelines International Classification of Functioning 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. Copyright © 2022, the American Hospital Association, Chicago, Illinois. 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; Physiologic impairment of functional status as demonstrated by: Karnofsky Performance Status (KPS) or Palliative Performance Score (PPS) < 70%. and the State Children's Health Insurance Programs, contracts with certain organizations to assist in the administration of the 0000040550 00000 n Also, you can decide how often you want to get updates. ), Hypoxemia at rest on room air, as evidenced by pO2 less than or equal to 55 mmHg, or oxygen saturation less than or equal to 88%, determined either by arterial blood gases or oxygen saturation monitors, (these values may be obtained from recent hospital records) OR hypercapnia, as evidenced by pCO2 greater than or equal to 50 mmHg. Frequently continue to be able to distinguish familiar from unfamiliar persons in their environment. without the written consent of the AHA. ), 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. 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. 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. Applications are available at the AMA Web site, http://www.ama-assn.org/go/cpt. Coverage for these patients may be approved if documentation otherwise supporting a less than six-month life expectancy is provided. The A.S.P.E.N. (1 and 2 should be present. There is no regulation precluding patients on dialysis from electing Hospice care. Severe chronic lung disease as documented by both a and b: Disabling dyspnea at rest, poorly or unresponsive to bronchodilators, resulting in decreased functional capacity, e.g., bed to chair existence, fatigue, and cough; (Documentation of Forced Expiratory Volume in One Second (FEV1), after bronchodilator, less than 30% of predicted is objective evidence for disabling dyspnea, but is not necessary to obtain. ACC/AHA Guidelines for the evaluation and management of chronic heart failure in the adult: executive summary, a report of the American college of cardiology/American heart association task force on practice guidelines (committee to revise the 1995 guidelines of the evaluation and management of heart failure). patients who should be at complete rest, confined to bed or chair; any physical activity brings on discomfort and symptoms occur at rest. This LCD describes guidelines to be used by National Government Services (NGS) in reviewing hospice claims and by hospice providers to determine eligibility of beneficiaries for hospice benefits. 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. Progressive decline in Functional Assessment Staging (FAST) for dementia (from 7A on the FAST). For example, severe protein-calorie malnutrition cannot be considered a MCC for the principle diagnosis of "Failure to Thrive" because the two conditions are too similar. PCM is estimated at 4% in the community setting; 29% in sub-acute care facilities; 27% and 38% among the hospitalized elderly aged 60 - 79 and aged 80 and older, respectively; and . 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. A52830 - Billing and Coding: Hospice: Determining Terminal Status. West J Med. Factors from 5 will lend supporting documentation. J Clin Oncology. Therefore, multiple clinical parameters are required to judge the progression of ALS. Please review and accept the agreements in order to view Medicare Coverage documents, which may include licensed information and codes. FVC < 40% predicted (seated or supine) and 2 or more of the following symptoms and/or signs: If unable to perform the FVC test patients meet this criterion if they manifest 3 or more of the above symptoms/signs. the medical record and for coders to be aware of malnutrition as a potential diagnosis (ICD-10-CM codes E44.0, E44.1 and E46). CMS and its products and services are not endorsed by the AHA or any of its affiliates. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely. They require no assistance with toileting and eating, but may have some difficulty choosing the proper clothing to wear. End User Point and Click Amendment: trailer ), Progression of end stage pulmonary disease, as evidenced by increasing visits to the emergency department or hospitalizations for pulmonary infections and/or respiratory failure or increasing physician home visits prior to initial certification. Denial is dominant defense mechanism. descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work Pain requiring increasing doses of major analgesics more than briefly. Manifestations in more than one of the following areas: Objective evidence of memory deficit obtained only with an intensive interview. Normal activity & work No evidence of disease, Normal activity & work Some evidence of disease, Normal activity with effort Some evidence of disease, Unable Normal Job/Work Significant disease, Unable hobby/house work Significant disease, Unable to do most activity Extensive disease, Unable to do any activity Extensive disease, Detailed Description of Each of the 7 Stages. Co-morbidities. Studies enrolling individuals with planned admissions (e.g. Documentation of 3, 4, and 5, will lend supporting documentation.). Revision Explanation: Annual review no changes made. Cachexia should have been listed as i. and not beside Albumin with ii, this has been corected. Stroke. Unspecified severe protein-calorie malnutrition. 0000003984 00000 n If you would like to extend your session, you may select the Continue Button. The criteria refer to patients with various forms of advanced pulmonary disease who eventually follow a final common pathway for end stage pulmonary disease. 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). However, no single variable deteriorates at a uniform rate in all patients. Disease with distant metastases at presentation ORB. Note: Certain cancers with poor prognoses (e.g. Clin Cardiol. authorized with an express license from the American Hospital Association. Severe chronic lung disease as documented by both a and b: Disabling dyspnea at rest, poorly or unresponsive to bronchodilators, resulting in decreased functional capacity, e.g., bed to chair existence, fatigue, and cough: (Documentation of Forced Expiratory Volume in One Second (FEV1), after bronchodilator, less than 30% of predicted is objective evidence for disabling dyspnea, but is not necessary to obtain. 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. While every effort has Before an LCD becomes final, the MAC publishes Proposed LCDs, which include a public comment period. An official website of the United States government. Stage 6 (Middle Dementia) Severe cognitive decline.May occasionally forget the name of the spouse upon whom they are entirely dependent for survival. patients with slight, mild limitation of activity; they are comfortable with rest or with mild exertion. Other clinical variables not on this list may support a six-month or less life expectancy. The AMA does not directly or indirectly practice medicine or dispense medical services. FAST scale. 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%. 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 Social Security Act, Sections 1869(f)(2)(B) and 1862(l)(5)(D) define LCDs and provide information on the process. Many patients exhibit symptoms of both disease states. 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. Any questions pertaining to the license or use of the CPT should be addressed to the AMA. Requires occasional assistance, but is able to care for most of his personal needs. Protein-Energy Malnutrition / diagnosis Serum Albumin / analysis Substances Amino Acids . presented in the material do not necessarily represent the views of the AHA. The views and/or positions Federal government websites often end in .gov or .mil. Lose basic psychomotor skills, e.g., ability to walk, sitting and head control. Documentation of the applicable criteria listed under the Indications section of this policy would meet this requirement. An asterisk (*) indicates a AJ Hospice & Palliative Care, 2003; 20; 41-51. Progression to dependence on assistance with additional activities of daily living (see Part II, Section 2). 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. of every MCD page. Revision Explanation: Annual review, no changes made. Nausea/vomiting poorly responsive to treatment. 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. 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. 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. While not necessarily a contraindication to Hospice care, the decision to institute either artificial ventilation or artificial feeding may significantly alter six month prognosis. 1999;22(6):385-90.Lamont E, Christakis N. Prognostic disclosure to patients with cancer near the end of life. The 2023 edition of ICD-10-CM E46 became effective on October 1, 2022. This email will be sent from you to the 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. 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. Although ALS usually presents in a localized anatomical area, the location of initial presentation does not correlate with survival time. malnutrition (263.0: Malnutrition of a Moderate Degree) and severe malnutrition (262: Other Severe Protein Calorie Malnutrition). Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by clicking below on the button labeled "I Accept". 2001;104:2996-3007. 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. 0000008075 00000 n 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. 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. Severely disabled; hospital admission is indicated although death not imminent. Disease Specific GuidelinesNote: These guidelines are to be used in conjunction with the Non-disease specific baseline guidelines described in Part II.Cancer Diagnoses. At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. British Medical Journal. N. Christakis, E. Lamont. undergoing non-emergent elective procedures), patients receiving or who have received hospice services, or pregnant women will not be considered for inclusion in this report. routine or continuous home or inpatient, respite, or general. Thus, the overall rate of decline in each patient is fairly constant and predictable, unlike many other non-cancer diseases. Extent and determinants of error in doctors prognoses in terminally ill patients: prospective cohort study. Severity of malnutrition is based on phenotypic criteria only and requires one phenotypic criterion that meets the threshold of . Factors from 4 will lend supporting documentation.). Creatinine clearance <10 cc/min (< 15 cc/min for diabetics); or < 15cc/min (< 20cc/min for diabetics) with comorbidity of congestive heart failure. Baseline data may be established on admission to hospice or by using existing information from records. 0000011855 00000 n 0000008839 00000 n Please enable "JavaScript" and revisit this page or proceed with browsing CMS.gov with While not necessarily a contraindication to Hospice Care, the decision to institute either artificial ventilation or artificial feeding will significantly alter six-month prognosis. ), Patients will be considered to be in the terminal stage of liver disease (life expectancy of six months or less) if they meet the following criteria. Physiologic impairment of functional status as demonstrated by: Dependence on assistance for two or more activities of daily living (ADLs), Neurologic disease (CVA, ALS, MS, Parkinsons). endstream endobj 657 0 obj <> endobj 658 0 obj <>stream Factors from 3 will add supporting documentation. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. E40 refers to Kwashiorkor is severe malnutrition with nutritional edema and dyspigmentation of skin and hair. Lab testing is not required to establish hospice eligibility. Patients with dementia should show all the following characteristics: Patients should have had one of the following within the past 12 months: Note: This section is specific for Alzheimers Disease and related disorders, and is not appropriate for other types of dementia, such as multi-infarct dementia. ), 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, 3 or 4 should be present. For principle diagnoses in which severe protein-calorie malnutrition could be listed as a MCC, there must be documentation demonstrating additional Requires considerable assistance and frequent medical care. Instructions for enabling "JavaScript" can be found here. Symptoms of heart failure or of the anginal syndrome may be present even at rest. 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. 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. + See Part III for disease specific guidelines to be used with these baseline guidelines. Applicable FARS\DFARS Restrictions Apply to Government Use. The score can help determine which patients can be managed in the home and which should be admitted to a hospice unit. Additionally, marasmus can precede kwashiorkor. 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. You can use the Contents side panel to help navigate the various sections. The AMA assumes no liability for data contained or not contained herein. Unable to dress without assistance. xref You are leaving the CMS MCD and are being redirected to the CMS MCD Archive that contains outdated (No Longer In Effect) Local Coverage Determinations and Articles, You are leaving the CMS MCD and are being redirected to, For services performed on or after 10/01/2015, For services performed on or after 06/30/2022, AMA CPT / ADA CDT / AHA NUBC Copyright Statement, Coverage Indications, Limitations, and/or Medical Necessity, Analysis of Evidence (Rationale for Determination), LCD - Hospice Determining Terminal Status (L34538). CEA, PSA); Progressively decreasing or increasing serum sodium or increasing serum potassium. E46 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. 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. Systemic hypertension; coronary artery disease; diabetes mellitus; history of cardiotoxic drug therapy or alcohol abuse; personal history of rheumatic fever; family history of cardiomyopathy.