For this reason, the history of the rate of progression in individual patients is important to obtain to predict prognosis. 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. You can use the Contents side panel to help navigate the various sections. Incontinent of urine, requires assistance toileting and feeding. 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. Significant congestive heart failure may be documented by an ejection fraction of 20%, but is not required if not already available. 0000000016 00000 n 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. The Social Security Act, Sections 1869(f)(2)(B) and 1862(l)(5)(D) define LCDs and provide information on the process. These should be documented in the clinical record. @7Eq p[3gXsm!t;ON-:5,lX`9^n:myuT.sf~RG}|^no\x XP\w( 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. 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; Intractable hyperkalemia (> 7.0) not responsive to treatment; Intractable fluid overload, not responsive to treatment. If other clinical indicators of decline not listed in this policy such as psychological and spiritual factors form the basis for certifying terminal status, they should be documented as well. LCD - Hospice - Determining Terminal Status (L33393) Please do not use this feature to contact CMS. 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> Patient is unable during interview to recall a major relevant aspect of their current lives, e.g., an address or telephone number of manyyears, the names of close family members (such as grandchildren), the name of the high school or college from which they graduated. National Government Services is not responsible for the continuing viability of Web site addresses listed below. Inability to maintain hydration and caloric intake with 1 of the following: weight loss >10% in the last 6 months or >7. . The use of the Karnofsky Performance Scale in determining outcomes and risk in geriatric outpatients. Nutritional supplementation is one of the most important interventions in patients with failure to thrive. Physiologic impairment of functional status as demonstrated by: Karnofsky Performance Status (KPS) or Palliative Performance Score (PPS) < 70%. All Rights Reserved (or such other date of publication of CPT). Studies enrolling individuals with planned admissions (e.g. You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement. Coverage for these patients may be approved if documentation otherwise supporting a less than six-month life expectancy is provided. Revision Explanation:Converted policy into new policy template that no longer includes coding section based on CR 10901. Revision Explanation: Annual review no changes made. 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. Use of CDT is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). Baker D, Chin M, Cinquigrani M, et al. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). - 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. Medicare contractors are required to develop and disseminate Local Coverage Determinations (LCDs). Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, 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. The score can help determine which patients can be managed in the home and which should be admitted to a hospice unit. 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 British Medical Journal. Most facts and observations tending to suggest a greater than 6 month prognosis are predictable and apparent, such as a prolonged stay in hospice or a low immediate mortality diagnosis, as stated above. Symptoms Include a number of symptoms, including nausea and vomiting, dyspnea, persisting cough, fatigue, decreased cognition, diarrhea, and progressive pain Signs Urinary and fecal incontinence, intermittent or constant; No consistently meaningful verbal communication: stereotypical phrases only or the ability to speak is limited to six or fewer intelligible words. The A.S.P.E.N. See 1869(f)(1)(A)(i) of the Social Security Act. 7500 Security Boulevard, Baltimore, MD 21244. Laboratory tests in protein-calorie malnutrition. 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. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be 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 AMA does not directly or indirectly practice medicine or dispense medical services. The document is broken into multiple sections. 2001;104:2996-3007. 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. Some patients may not meet these guidelines, yet still have a life expectancy of 6 months or less. These materials contain Current Dental Terminology (CDTTM), copyright© 2022 American Dental Association (ADA). (This value may be obtained from recent [within 3 months] hospital records.). The views and/or positions 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. Disease-specific guidelines for hospice - UpToDate 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). 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. <]/Prev 527120/XRefStm 1970>> E. Lamont, N. Christakis. of every MCD page. Hospitals Overbilled Medicare $1 Billion by Incorrectly Assigning copied without the express written consent of the AHA. Frequently no deficit in the following areas: Inability to perform complex tasks. J Palliative Medicine 2002; 5; 73-84. (1 and 2 should be present. Medicare contractors are required to develop and disseminate Local Coverage Determinations (LCDs). Made a technical update to this LCD to remove the empty Coding Information fields. Any questions pertaining to the license or use of the CPT should be addressed to the AMA. As each patient is unique, there are patients for whom a particular guideline does not match. Hospice Eligibility Criteria Patient has a terminal illness with a life . Baseline data may be established on admission to hospice or by using existing information from records. ; Supratentorial: greater than or equal to 50 ml. 0000037087 00000 n 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. startxref 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.
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