0000040858 00000 n These should be documented in the clinical record.These changes in clinical variables apply to patients whose decline is not considered to be reversible. 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. Speech ability declines to about a half-dozen intelligible words. Healthcare providers retain responsibility to submit complete and accurate. They may be incorporated by specific reference as part (or all) of the indication for recertification. Extent and determinants of error in doctors prognoses in terminally ill patients: prospective cohort study. small cell lung cancer, brain cancer and pancreatic cancer) may be hospice eligible without fulfilling the other criteria in this section. Stage 5 (Early Dementia) Moderately severe cognitive decline. Nausea/vomiting poorly responsive to treatment. This is the American ICD-10-CM version of E43 - other international versions of ICD-10 E43 may differ. 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. Patients 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. 0000012920 00000 n The New York Heart Association (NYHA) Functional Classification provides a simple way of classifying heart disease (originally cardiac failure). 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. patient declines further disease directed therapyNote: Certain cancers with poor prognoses (e.g. Before an LCD becomes final, the MAC publishes Proposed LCDs, which include a public comment period. Other clinical variables not on this list may support a six-month or less life expectancy. and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only The score can help determine which patients can be managed in the home and which should be admitted to a hospice unit. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or 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. Physiologic impairment of functional status as demonstrated by: Karnofsky Performance Status (KPS) or Palliative Performance Score (PPS) < 70%. 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. 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). The lower the Karnofsky score, the worse the survival for most serious illnesses.KARNOFSKY PERFORMANCE STATUS SCALE DEFINITIONS RATING (%) CRITERIA. trailer LCDs outline how the contractor will review claims to ensure that the services provided meet Medicare coverage requirements. This Agreement will terminate upon notice if you violate its terms. Applications are available at the AMA Web site, http://www.ama-assn.org/go/cpt. 0000008742 00000 n 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. National Government Services is not responsible for the continuing viability of Web site addresses listed below. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. 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. Coding professionals would use ICD-10-CM code E43 to report severe malnutrition, also known as starvation edema. Factors from 3 will add supporting documentation. THE INFORMATION, PRODUCT, OR PROCESSES DISCLOSED HEREIN. Current Dental Terminology © 2022 American Dental Association. Before sharing sensitive information, make sure you're on a federal government site. required field. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT. 0000060832 00000 n Laboratory tests in protein-calorie malnutrition. 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. 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 AMA assumes no liability for data contained or not contained herein. Please visit the. These changes in clinical variables apply to patients whose decline is not considered to be reversible. E46 - Unspecified protein calorie malnutrition E64 - Sequelae of protein calorie malnutrition. 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 . THE INFORMATION, PRODUCT, OR PROCESSES DISCLOSED HEREIN. AJ Hospice & Palliative Care. West J Med. Unintentional progressive weight loss of greater than 10% of body weight over the preceding six months. 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. Applicable FARS\DFARS Restrictions Apply to Government Use. 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. The Tracking Sheet modal can be closed and re-opened when viewing a Proposed LCD. Applications are available at the AMA Web site, http://www.ama-assn.org/go/cpt. You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement. (1 and 2 should be present; factors from 3 will add supporting documentation. Factors from 5 will lend supporting documentation. (1 and 2 should be present, factors from 3 will lend supporting documentation. 0000006339 00000 n 0000001970 00000 n Patients 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. ), 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. Clinical variables with general applicability without regard to diagnosis, as well as clinical variables applicable to a limited number of specific diagnoses, are provided. License to use CDT for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. 0000012375 00000 n Progression of disease differs markedly from patient to patient. 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. Any questions pertaining to the license or use of the CPT should be addressed to the AMA. Other clinical variables not on this list may support a six-month or less life expectancy. 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. 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. Symptoms of heart failure or of the anginal syndrome may be present even at rest. 0000008839 00000 n 646 0 obj <> endobj Marasmus, or PEM without edema, is . (1 and 2 should be present. Please visit the, Progression of disease as documented by worsening clinical status, symptoms, signs and laboratory results. 0000022017 00000 n For this reason, the history of the rate of progression in individual patients is important to obtain to predict prognosis. Incontinent of urine, requires assistance toileting and feeding. Secondary Criteria Notes . and the State Children's Health Insurance Programs, contracts with certain organizations to assist in the administration of the Surface area of involvement of hemorrhage 30% of cerebrum; Obstructive hydrocephalus in patient who declines, or is not a candidate for, ventriculoperitoneal shunt. 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 LCDs are specific to an item or service (procedure) and they define the specific diagnosis (illness or injury) for which the item or service is covered. not endorsed by the AHA or any of its affiliates. Large anterior infarcts with both cortical and subcortical involvement; Upper urinary tract infection (pyelonephritis); Medicare Contractor Medical Directors' Hospice Workgroup, B. Friedman, M. Harwood, M. Shields. of every MCD page. 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. Unable to work; able to live at home and care for most personal needs; varying amount of assistance needed. copied without the express written consent of the AHA. ), Chronic Kidney Disease (1 and either 2, 3 or 4 should be present. 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. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials. 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. Use of CDT is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). Accessed 01/16/2008.Schag CC, Heinrich RL, Ganz, PA. Karnofsky performance status revisited: Reliability, validity, and guidelines. CEA, PSA); Progressively decreasing or increasing serum sodium or increasing serum potassium. The page could not be loaded. They are listed in order of their likelihood to predict poor survival, the most predictive first and the least predictive last. The former can be managed by artificial ventilation, and the latter by gastrostomy or other artificial feeding, unless the patient has recurrent aspiration pneumonia. However, the continuation of dialysis will significantly alter a patients prognosis, and thus potentially impact that individuals eligibility. hb``g``og`e`8 @1v'00?07)&=y a"WF9e*())vt4xLJJ 6x5;E8X>0~b !a;"cCm)'01d93f00,a``VF? o000h36(`a`h'a~6AAj@Ae\T@6 M> Part II. Baseline data may be established on admission to hospice or by using existing information from records. A52830 - Billing and Coding: Hospice: Determining Terminal Status. These materials contain Current Dental Terminology (CDTTM), copyright© 2022 American Dental Association (ADA). 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%. ALS tends to progress in a linear fashion over time. Please review and accept the agreements in order to view Medicare Coverage documents, which may include licensed information and codes. "JavaScript" disabled. The document is broken into multiple sections. However, documentation expectations should comport with normal clinical documentation practices. 1993:109.Friedman B, Harwood S. Barriers and enablers to hospice referrals: an expert overview. 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. Therefore, multiple clinical parameters are required to judge the progression of ALS. Coverage for these patients may be approved if documentation otherwise supporting a less than six-month life expectancy is provided.Section 322 of BIPA amended section 1814(a) of the Social Security Act by clarifying that the certification of an individual who elects hospice "shall be based on the physician's or medical director's clinical judgment regarding the normal course of the individual's illness.'' Ogle K, Mavis B, Wang T. Hospice and primary care physicians: attitudes, knowledge, and barriers. Baseline data may be established on admission to hospice or by using existing information from records. > Dependence on assistance for two or more activities of daily living (ADLs): Co-morbidities although not the primary hospice diagnosis, the presence of disease such as the following, the severity of which is likely to contribute to a life expectancy of six months or less, should be considered in determining hospice eligibility. Retain some knowledge of their past lives but this is very sketchy. Disabled; requires special care and assistance. 0000017875 00000 n Appropriate concern regarding symptoms. 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. H\n0)B-FZBo>9X;frYQkh!:?^rt:wn/6]rO7go7c?[\zVi/6K]9bKCO1r{O=fU%=Xfey.)2"/g6_n. Your MCD session is currently set to expire in 5 minutes due to inactivity. The LCD Tracking Sheet is a pop-up modal that is displayed on top of any Proposed LCD that began to appear on the MCD on or after 1/1/2022. Although ALS usually presents in a localized anatomical area, the location of initial presentation does not correlate with survival time. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely. The CMS.gov Web site currently does not fully support browsers with Factors from 5 will lend supporting documentation. descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work authorized with an express license from the American Hospital Association. Please note that if you choose to continue without enabling "JavaScript" certain functionalities on this website may not be available. Diurnal rhythm frequently disturbed. In critically ill patients, these alterations can. You can use the Contents side panel to help navigate the various sections. They require no assistance with toileting and eating, but may have some difficulty choosing the proper clothing to wear. 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. ), Hypoxemia at rest on room air, as evidenced by pO2 55 mmHg; or oxygen saturation 88%, determined either by arterial blood gases or oxygen saturation monitors; (These values may be obtained from recent hospital records.) ; Obstructive hydrocephalus in patient who declines, or is not a candidate for, ventriculoperitoneal shunt. CPT codes, descriptions and other data only are copyright 2022 American Medical Association. Protein calorie malnutrition happens when you are not consuming enough protein and calories. This bibliography presents those sources that were obtained during the development of this policy. The responsibility for the content of this file/product is with CMS and no endorsement by the AMA is intended or implied. 26 Because the goal of dietary supplements is to provide adequate energy and protein. 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. All Rights Reserved (or such other date of publication of CPT). + (Documentation of serial decrease of FEV1>40 ml/year is objective evidence for disease progression, but is not necessary to obtain. 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. Progression from an earlier stage of disease to metastatic disease with either: A continued decline in spite of therapy; or. Decline in systolic blood pressure to below 90 or progressive postural hypotension, Venous, arterial or lymphatic obstruction due to local progression or metastatic disease, Laboratory (When available. Nutritional supplementation is one of the most important interventions in patients with failure to thrive. http://www.ed-online.net\. CPT codes, descriptions and other data only are copyright 2022 American Medical Association. Applicable FARS\DFARS Restrictions Apply to Government Use. endstream endobj 657 0 obj <> endobj 658 0 obj <>stream Hospice and primary care physicians: attitudes, knowledge, and barriers. Similarly, . Inability to maintain sufficient fluid and calorie intake in past 6 months (10% weight loss or albumin <2.5) . Measuring quality of life in stroke. ]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 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". Journal of Palliative Medicine. Patients will be considered to be in the terminal stage of dementia (life expectancy of six months or less) if they meet the following criteria. Revision Explanation:Converted policy into new policy template that no longer includes coding section based on CR 10901. 2001;104:2996-3007. The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. It was developed in British Columbia, Canada. Please do not use this feature to contact CMS. 0000016419 00000 n The guidelines for LCD development are provided in Chapter 13 of the Medicare Program Integrity Manual. Patients who have current or prior symptoms of HF associated with underlying structural heart disease. R8Revision Effective: 05/06/2021Revision Explanation: Corrected typo in the associated information section under acute renal failure. 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. Section 322 of BIPA amended section 1814(a) of the Social Security Act by clarifying that the certification of an individual who elects hospice "shall be based on the physician's or medical director's clinical judgment regarding the normal course of the individual's illness.'' 0000009368 00000 n Amyotrophic Lateral Sclerosis General Considerations: Criteria:Patients will be considered to be in the terminal stage of ALS (life expectancy of six months or less) if they meet the following criteria. Documentation of the applicable criteria listed under the Indications section of this policy would meet this requirement. The responsibility for the content of this file/product is with CMS and no endorsement by the AMA is intended or implied. Lupus or Rheumatoid Arthritis). Include supporting events such as a change in the level of activities of daily living, recent hospitalizations, and the known date of death (if you are billing for a period of time prior to the billing period in which death occurred. These materials contain Current Dental Terminology (CDTTM), copyright© 2022 American Dental Association (ADA). End User Point and Click Amendment: Factors from 3 will add supporting documentation. 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. H\0E Muscle wasting with reduced strength and endurance; Continued active alcoholism (> 80 gm ethanol/day); Hepatitis C refractory to interferon treatment. Requires considerable assistance and frequent medical care. 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. In end-state ALS, two factors are critical in determining prognosis: ability to breathe, and to a lesser extent ability to swallow. startxref End User License Agreement: This page displays your requested Local Coverage Determination (LCD). 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. Instructions for enabling "JavaScript" can be found here. Dyspnea or fatigue due to left ventricular systolic dysfunction; asymptomatic patients who are undergoing treatment for prior symptoms of HF. CDT is a trademark of the ADA. 2000;320:469-472.Crooks V, Waller S, Smith T, Hahn TJ. This page displays your requested Local Coverage Determination (LCD). Although guidelines applicable to certain disease categories are included, this LCD is applicable to all hospice patients. 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. THE UNITED STATES GOVERNMENT AND ITS EMPLOYEES ARE NOT LIABLE FOR ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN Persons at this stage retain knowledge of many major facts regarding themselves and others. 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. 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. The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. 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. CMS and its products and services are not endorsed by the AHA or any of its affiliates. Medicare contractors are required to develop and disseminate Local Coverage Determinations (LCDs). J Palliative Medicine. The views and/or positions 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. 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. 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 Unable to dress without assistance. ), Pulmonary DiseasePatients 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. In such cases, it is important for providers to meticulously document the factors which specify the individuals terminal prognosis.There are also patients who match a guideline at the start of hospice care, and who continue to do so for a prolonged period, e.g., greater than six months. 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. Undernutrition happens when you don't consume enough essential nutrients, or when you use/excrete the nutrients faster than they are replaced (1). The AMA does not directly or indirectly practice medicine or dispense medical services. Decline in Karnofsky Performance Status (KPS ) or Palliative Performance Score (PPS) due to progression of disease. 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. There has been no change in coverage with this LCD revision. However, the continuation of dialysis will significantly alter a patients prognosis, and thus potentially impact that individuals eligibility.