British Medical Journal 2000; 320; 469-472. descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work
Serum creatinine > 8.0 mg/dl (>6.0 mg/dl for diabetics). Some patients may not meet these guidelines, yet still have a life expectancy of six months or less. 1984;2:187-193. 0000037443 00000 n
Requires occasional assistance, but is able to care for most of his personal needs. (Class IV patients with heart disease have an inability to carry on any physical activity. preparation of this material, or the analysis of information provided in the material. 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". Retain some knowledge of their past lives but this is very sketchy. Recommendation: Target blood glucose range of 140 - 180 mg\dL for the general ICU population. Some patients decline rapidly and die quickly; others progress more slowly. The score can help determine which patients can be managed in the home and which should be admitted to a hospice unit. Some patients may not meet these guidelines, yet still have a life expectancy of six months or less. 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. 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. Documentation of 3, 4, and 5, will lend supporting documentation.). ALS tends to progress in a linear fashion over time. Revision Explanation: Annual review no changes were made. Circulation. Right heart failure (RHF) secondary to pulmonary disease (Cor pulmonale) (e.g., not secondary to left heart disease or valvulopathy). CPT codes, descriptions and other data only are copyright 2022 American Medical Association. 0000012920 00000 n
You are leaving the CMS MCD and are being redirected to the CMS MCD Archive that contains outdated (No Longer In Effect) Local Coverage Determinations and Articles, You are leaving the CMS MCD and are being redirected to, For services performed on or after 10/01/2015, For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 11/14/2019, AMA CPT / ADA CDT / AHA NUBC Copyright Statement. decreased knowledge of current and recent events; may exhibit some deficit in memory of one's personal history; concentration deficit elicited on serial subtractions; decreased ability to travel, handle finances, etc. CEA, PSA); Progressively decreasing or increasing serum sodium or increasing serum potassium. Pain requiring increasing doses of major analgesics more than briefly. 26 Because the goal of dietary supplements is to provide adequate energy and protein. Frequently there is no speech at all - only grunting. 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. An educated person may have difficulty counting back from 40 by 4s or from 20 by 2s. 0000003984 00000 n
), 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. These changes in clinical variables apply to patients whose decline is not considered to be reversible. Maybe it's the phenolic phytonutrients within flora which can be supporting, supported by way of proof that "sure vegetarian diets" appear to relieve "the severity of pores and skin illnesses" in adults with eczemathough in case you have a look at that quotation, it become a totally . In critically ill patients, these alterations can. 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. All rights reserved. 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. Progressive decline in Functional Assessment Staging (FAST) for dementia (from 7A on the FAST). These guidelines are to be used in conjunction with the Non-disease specific baseline guidelines described in Part II. 0000037874 00000 n
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. Karnofsky Performance Status (KPS) or Palliative Performance Scale (PPS) of 40% or less; 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. ), 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. Accessed 01/16/2008.Schag CC, Heinrich RL, Ganz, PA. Karnofsky performance status revisited: Reliability, validity, and guidelines. 2000;320:469-472.Crooks V, Waller S, Smith T, Hahn TJ. (1 and 2 should be present; factors from 3 will add supporting documentation. End User License Agreement:
for diabetics); or < 15cc/min (< 20cc/min for diabetics) with comorbidity of congestive heart failure. 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. 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. 0000013372 00000 n
Baseline data may be established on admission to hospice or by using existing information from records. Normal activity with effort; some signs or symptoms of disease. HMn1>.`Ax! 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. Progression from an earlier stage of disease to metastatic disease with either:1. a continued decline in spite of therapy2. Disabled; requires special care and assistance. 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. Earliest clear-cut deficits. Instructions for enabling "JavaScript" can be found here. 7500 Security Boulevard, Baltimore, MD 21244. R2Revision Effective: N/ARevision Explanation: Annual review no changes made. 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. The use of the Karnofsky Performance Scale in determining outcomes and risk in geriatric outpatients. In no event shall CMS be liable for direct, indirect,
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Frequently some disorientation to time (date, day of week, season, etc.) 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.'' End User License Agreement:
LCDs outline how the contractor will review claims to ensure that the services provided meet Medicare coverage requirements. Factors from 5 will lend supporting documentation. 0000017875 00000 n
Personality and emotional changes occur. (1 and 2 should be present; factors from 3 will add supporting documentation. In end-state ALS, two factors are critical in determining prognosis: ability to breathe, and to a lesser extent ability to swallow. Symptoms of heart failure or of the anginal syndrome may be present even at rest. May have difficulty counting from 10, both backward and sometimes forward. The views and/or positions
The reviewer should be able to easily identify the dates and times of changes in levels of care and the reason for the change.In addition the documentation must comply with the requirements found in accordance with CMS IOM 100-02 Chapter 9 Section 20.Disease Specific GuidelinesNote: These guidelines are to be used in conjunction with the Non-disease specific baseline guidelines described in Part II of the basic policy.Section I: Cancer Diagnoses A. For this reason, the history of the rate of progression in individual patients is important to obtain to predict prognosis. 1993:109.Friedman B, Harwood S. Barriers and enablers to hospice referrals: an expert overview. 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. Factors from 3 will add supporting documentation. While not necessarily a contraindication to Hospice Care, the decision to institute either artificial ventilation or artificial feeding will significantly alter six-month prognosis. Coverage for these patients may be approved if documentation otherwise supporting a less than six-month life expectancy is provided. 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. While these characteristics are assessed along a continuum, rather than as discrete variables, they are useful in formulating and documenting a diagnosis of malnutrition. 0000040858 00000 n
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Evaluating cancer patients for rehabilitation potential. 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. 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. The guidelines for LCD development are provided in Chapter 13 of the Medicare Program Integrity Manual. Decline in systolic blood pressure to below 90 or progressive postural hypotension; Venous, arterial or lymphatic obstruction due to local progression or metastatic disease; Increasing pCO2 or decreasing pO2 or decreasing SaO2; Increasing calcium, creatinine or liver function studies; Increasing tumor markers (e.g. Studies enrolling individuals with planned admissions (e.g. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be
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The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or
K. Ogle, B. Mavis, G. Wyatt. CPT codes, descriptions and other data only are copyright 2022 American Medical Association. recipient email address(es) you enter. It does not mean, however, that meeting the guideline is obligatory. They may be incorporated by specific reference as part (or all) of the indication for recertification. 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. 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. 0000040363 00000 n
Examination by a neurologist within three months of assessment for hospice is advised, both to confirm the diagnosis and to assist with prognosis. The AMA assumes no liability for data contained or not contained herein. sensitive to and specic for protein-calorie malnutrition.4 Serum hepatic protein levels help the clinician to identify the sickest of patientsthose who may be more likely to develop malnutrition.1 It is imperative that the registered dietitian nutritionist in-terprets hepatic protein levels in the context of the patient's overall health By the time patients become end-stage, muscle denervation has become widespread, affecting all areas of the body, and initial predominance patterns do not persist. General Guidelines:Documentation certifying terminal status must contain enough information to support terminal status upon 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. You can use the Contents side panel to help navigate the various sections. 0000061858 00000 n
1991;155:384-387.Reisberg B. ElderCare online. ), (1 and either 2 or 3 should be present. Significant congestive heart failure may be documented by an ejection fraction of 20%, but is not required if not already available. J Palliative Medicine 2002; 5; 85-92. RegVUA]rj N{ 8Qs. 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". CPT is a trademark of the American Medical Association (AMA). Large anterior infarcts with both cortical and subcortical involvement. Journal of Palliative Medicine. (1 and 2 should be present. Use is limited to use in Medicare, Medicaid or other programs administered by the Centers for Medicare and Medicaid Services (CMS). Secondary Criteria Notes . Hospice Eligibility Criteria Patient has a terminal illness with a life . J Clin Oncology. Nausea/vomiting poorly responsive to treatment. All Rights Reserved (or such other date of publication of CPT). preparation of this material, or the analysis of information provided in the material. Also, you can decide how often you want to get updates. Medicare contractors are required to develop and disseminate Local Coverage Determinations (LCDs). These materials contain Current Dental Terminology (CDTTM), copyright© 2022 American Dental Association (ADA). recipient email address(es) you enter. End Users do not act for or on behalf of the CMS. Please do not use this feature to contact CMS. (Should fulfill 1, 2, or 3). (Class IV patients with heart disease have an inability to carry on any physical activity without discomfort. ), 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. on this web site. 0000004710 00000 n
Severity of malnutrition is based on phenotypic criteria only and requires one phenotypic criterion that meets the threshold of . 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. The CMS.gov Web site currently does not fully support browsers with
Mild protein-calorie malnutrition (weight for age 75-89% of standard) Protein calorie malnutrition, mild (gomez 75-90% s ICD-10-CM E44.1 is grouped within Diagnostic Related Group (s) (MS-DRG v40.0): 640 Miscellaneous disorders of nutrition, metabolism, fluids and electrolytes with mcc A52830 - Billing and Coding: Hospice: Determining Terminal Status. An official website of the United States government. 0000005335 00000 n
An asterisk (*) indicates a
Physiologic impairment of functional status as demonstrated by: Karnofsky Performance Status (KPS) or Palliative Performance Score (PPS) < 70%. 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. 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
t'h0&@,41%;j4aJEG>wJ4RA0^c Any questions pertaining to the license or use of the CPT should be addressed to the AMA. This section is specific for Alzheimers disease and Related Disorders, and is not appropriate for other types of dementia. The criteria refer to patients with various forms of advanced pulmonary disease who eventually follow a final common pathway for end stage pulmonary disease. 0000037087 00000 n
Note: This section is specific for Alzheimers disease and Related Disorders, and is not appropriate for other types of dementia.Heart DiseasePatients 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. E46 - Unspecified protein calorie malnutrition E64 - Sequelae of protein calorie malnutrition. 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. 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. 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. Revision Explanation: Annual review no changes made. 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. 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. The most severe malnutrition problems are associated with protein-calorie malnutrition (PCM), also known as protein-energy malnutrition or protein calorie undernutrition, which occurs in both chronic and acute forms. As each patient is unique, there are patients for whom a particular guideline does not match. Although ALS usually presents in a localized anatomical area, the location of initial presentation does not correlate with survival time. - 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. 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. 0
Use of CDT is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions;
The former can be managed by artificial ventilation, and the latter by gastrostomy or other artificial feeding, unless the patient has recurrent aspiration pneumonia. %PDF-1.4
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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. Proposed LCD document IDs begin with the letters "DL" (e.g., DL12345). If any physical activity is undertaken, discomfort is increased.) These are quite variable and include: Stage 7 (Late Dementia) Very severe cognitive decline. 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. The brain appears to no longer be able to tell the body what to do. CDT is a trademark of the ADA. 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. 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. documentation. 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 population for key question 3 will only include patients with a diagnosis of protein-energy malnutrition. THE UNITED STATES GOVERNMENT AND ITS EMPLOYEES ARE NOT LIABLE FOR ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN
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on this web site. Severely disabled; hospital admission is indicated although death not imminent. Requires assistance in complicated tasks such as handling finances, planning parties,etc. Pyelonephritis or other upper urinary tract infection; Inability to maintain sufficient fluid and calorie intake with 10% weight loss during the previous six months or serum albumin <2.5 gm/dl. Some older versions have been archived. (1 and 2 should be present; factors from 3 will add supporting documentation): 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. 0000003355 00000 n
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. Patients with chronic lung disease, long term survival in hospice, or apparent stability can still be eligible for hospice benefits, but sufficient justification for a less than six month prognosis should appear in the record.If the documentation includes any findings inconsistent with or tending to disprove a less than 6-month prognosis, they should be answered or refuted by other entries, or specifically addressed and explained. 0000008075 00000 n
Please note that if you choose to continue without enabling "JavaScript" certain functionalities on this website may not be available. and the State Children's Health Insurance Programs, contracts with certain organizations to assist in the administration of the
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. 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. Muscle wasting with reduced strength and endurance; Continued active alcoholism (> 80 gm ethanol/day); Hepatitis C refractory to interferon treatment. The guidelines for LCD development are provided in Chapter 13 of the Medicare Program Integrity Manual. 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. hbbRc`b``3
1x4>.0 Stage2 (Forgetfulness)Very mild cognitive decline. If you are experiencing any technical issues related to the search, selecting the 'OK' button to reset the search data should resolve your issues. The AMA is a third party beneficiary to this Agreement. and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only
The document is broken into multiple sections. and the State Children's Health Insurance Programs, contracts with certain organizations to assist in the administration of the
The patient is not seeking dialysis or renal transplant or is discontinuing dialysis; Serum creatinine >8.0 mg/dl (>6.0 mg/dl for diabetics); Intractable hyperkalemia (>7.0) not responsive to treatment; Intractable fluid overload, not responsive to treatment. 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. Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes,
While not necessarily a contraindication to Hospice care, the decision to institute either artificial ventilation or artificial feeding may significantly alter six month prognosis. Speech ability declines to about a half-dozen intelligible words. 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. The New York Heart Association (NYHA) Functional Classification provides a simple way of classifying heart disease (originally cardiac failure). CPT codes, descriptions and other data only are copyright 2022 American Medical Association. Before an LCD becomes final, the MAC publishes Proposed LCDs, which include a public comment period. The Social Security Act, Sections 1869(f)(2)(B) and 1862(l)(5)(D) define LCDs and provide information on the process. Progression from an earlier stage of disease to metastatic disease with either: A continued decline in spite of therapy; or. 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.
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