2022.08.24 WednesdayThe score can help determine which patients can be managed in the home and which should be admitted to a hospice unit. on this web site. Although guidelines applicable to certain disease categories are included, this LCD is applicable to all hospice patients. 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. There are multiple ways to create a PDF of a document that you are currently viewing. Such patients have no identified structural or functional abnormalities of the pericardium, myocardium, or cardiac valves and have never shown signs or symptoms of HF. In no event shall CMS be liable for direct, indirect, hbbRc`b``3 1x4>.0 The CMS.gov Web site currently does not fully support browsers with Neither the United States Government nor its employees represent that use of CPT codes, descriptions and other data only are copyright 2022 American Medical Association. Use is limited to use in Medicare, Medicaid or other programs administered by the Centers for Medicare and Medicaid Services (CMS). 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. 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. In no event shall CMS be liable for direct, indirect, The Tracking Sheet provides key details about the Proposed LCD, including a summary of the issue, who requested the new/updated policy, links to key documents, important process-related dates, who to contact with questions about the policy, and the history of previous policy considerations. You can use the Contents side panel to help navigate the various sections. Nausea/vomiting poorly responsive to treatment. Pulmonary Disease. You are leaving the CMS MCD and are being redirected to the CMS MCD Archive that contains outdated (No Longer In Effect) Local Coverage Determinations and Articles, You are leaving the CMS MCD and are being redirected to, For services performed on or after 10/01/2015, For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). 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. 0000005794 00000 n ), Stroke and ComaPatients will be considered to be in the terminal stages of stroke or coma (life expectancy of six months or less) if they meet the following criteria:Stroke, The guidelines contained in this policy are intended to help providers determine when patients are appropriate for the Medicare Hospice benefit. An educated person may have difficulty counting back from 40 by 4s or from 20 by 2s. 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". routine or continuous home or inpatient, respite, or general. AbstractMedicare 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. 2003;20: 41-51.Ogle K, Mavis B, Wang T. Physicians and hospice care: attitudes, knowledge and referrals. Some patients may not meet these guidelines, yet still have a life expectancy of six months or less. These guidelines are to be used in conjunction with the Non-disease specific baseline guidelines described in Part II. 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. ), 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. Other clinical variables not on this list may support a six-month or less life expectancy. without the written consent of the AHA. Retain some knowledge of their past lives but this is very sketchy. Stage 1No cognitive decline. Hence, it was concluded that albumin cannot be reliably used as a marker for diagnosing protein-calorie malnutrition . Clin Cardiol. H\n0)B-FZBo>9X;frYQkh!:?^rt:wn/6]rO7go7c?[\zVi/6K]9bKCO1r{O=fU%=Xfey.)2"/g6_n. Revision Explanation: Annual review no changes made. Frequently there is no speech at all - only grunting. CMS and its products and services are not endorsed by the AHA or any of its affiliates. ALS tends to progress in a linear fashion over time. Unspecified protein-calorie malnutrition. 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. Documentation of 3, 4, and 5, will lend supporting documentation. British Medical Journal. J Clin Oncology. small cell lung cancer, brain cancer and pancreatic cancer) may be hospice eligible without fulfilling the other criteria in this section. THE UNITED STATES GOVERNMENT AND ITS EMPLOYEES ARE NOT LIABLE FOR ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN 0000013372 00000 n 0000060832 00000 n 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. 0000002310 00000 n For this reason, the history of the rate of progression in individual patients is important to obtain to predict prognosis. 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. They may be incorporated by specific reference as part (or all) of the indication for recertification. Protein-calorie malnutrition (PCM) occurs when a child doesn't eat enough proteins and calories to meet nutritional needs. Other clinical variables not on this list may support a six-month or less life expectancy. Many patients exhibit symptoms of both disease states. The patient is not seeking dialysis or renal transplant, or is discontinuing dialysis. However, the amendment regarding the physician's clinical judgment does not negate the fact that there must be a basis for a certification. The criteria refer to patients with various forms of advanced pulmonary disease who eventually follow a final common pathway for end stage pulmonary disease. While every effort has In end-state ALS, two factors are critical in determining prognosis: ability to breathe, and to a lesser extent ability to swallow. descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work 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. Some older versions have been archived. Baseline data may be established on admission to hospice or by using existing information from records. It is rare occurrence in the U.S. E41 is used to report nutritional marasmus, a form of malnutrition characterized by consumption of . Also, you can decide how often you want to get updates. (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. 0000039022 00000 n All Rights Reserved. Protein Calorie Malnutrition Severe Protein Calorie Malnutrition Moderate Protein Calorie Malnutrition Severe Protein Calorie Malnutrition Energy Intake <75% of EEE >7 days 50 % of EEE >5 days <75% of EEE 1 month <75% of EEE 1 month <75% of EEE 3 months 50% of EEE 1 month Weight Loss Diurnal rhythm frequently disturbed. Factors from 5 will lend supporting documentation. 1999;22(6):385-90.Lamont E, Christakis N. Prognostic disclosure to patients with cancer near the end of life. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. Documentation of the applicable criteria listed under the Indications section of this policy would meet this requirement. The Centers for Medicare & Medicaid Services (CMS), the federal agency responsible for administration of the Medicare, Medicaid 0000040363 00000 n 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; 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. Critically impaired respiratory function is as defined by: Severe nutritional insufficiency is defined as: Dysphagia with progressive weight loss of at least five percent of body weight with or without election for gastrostomy tube insertion. Please review and accept the agreements in order to view Medicare Coverage documents, which may include licensed information and codes. CDT is a trademark of the ADA. Symptoms of heart failure or of the anginal syndrome may be present even at rest. The brain appears to no longer be able to tell the body what to do. 2001;104:2996-3007. See Part III for disease specific guidelines to be used with these baseline guidelines. 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. descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work Any questions pertaining to the license or use of the CPT should be addressed to the AMA. Unable to dress without assistance. Experiences urinary and fecal incontinence. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely. The AMA assumes no liability for data contained or not contained herein. 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. 646 0 obj <> endobj Normal activity with effort; some signs or symptoms of disease. Progressive malnutrition, muscle wasting with dec. strength, ongoing alcoholism (>80 gm . 0000003910 00000 n These materials contain Current Dental Terminology (CDTTM), copyright© 2022 American Dental Association (ADA). Applications are available at the American Dental Association web site. Protein-Energy Malnutrition / diagnosis Serum Albumin / analysis Substances Amino Acids . Co-morbidities. The Social Security Act, Sections 1869(f)(2)(B) and 1862(l)(5)(D) define LCDs and provide information on the process. Unintentional progressive weight loss of greater than 10% of body weight over the preceding six months. If a patient improves and/or stabilizes sufficiently over time while in hospice such that he/she no longer has a prognosis of six months or less from the most recent recertification evaluation or definitive interim evaluation, that patient should be considered for discharge from the Medicare hospice benefit. First, make sure the malnutrition meets the definition of a secondary diagnosisi.e., is there evaluation, monitoring, treatment, increased nursing care and/or increased length of stay. Requires considerable assistance and frequent medical care. This is the American ICD-10-CM version of E43 - other international versions of ICD-10 E43 may differ. 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. Left ventricular hypertrophy or fibrosis; left ventricular dilatation or hypocontractility; asymptomatic valvular heart disease; previous myocardial infarction. FAST scale. + . 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. (Optimally treated means that patients who are not on vasodilators have a medical reason for refusing these drugs, e.g., hypotension or renal disease.). If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816. The Tracking Sheet modal can be closed and re-opened when viewing a Proposed LCD. You, your employees and agents are authorized to use CPT only as agreed upon with the AMA internally within your organization within the United States for the sole use by yourself, employees and agents. AJ Hospice & Palliative Care, 2003; 20; 41-51. Each type may be classified as acute or chronic. This LCD outlines coverage for hospice as indicated in the coverage and indications section. (Class IV patients with heart disease have an inability to carry on any physical activity without discomfort. 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 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. Instructions for enabling "JavaScript" can be found here. An asterisk (*) indicates a To submit a comment or question to CMS, please use the Feedback/Ask a Question link available at the bottom 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. Protein-energy malnutrition (PEM) is classically described as 1 of 2 syndromes, marasmus and kwashiorkor, depending on the presence or absence of edema. There is no regulation precluding patients on dialysis from electing Hospice care. Although guidelines applicable to certain disease categories are included, this policy is applicable to all hospice patients. Severely disabled; hospital admission is indicated although death not imminent. special, incidental, or consequential damages arising out of the use of such information, product, or process. preparation of this material, or the analysis of information provided in the material. Stage 3 (Early Confusional)Mild cognitive decline. Applications are available at the American Dental Association web site. Requires assistance in choosing proper attire. It was developed in British Columbia, Canada. Protein calorie malnutrition happens when you are not consuming enough protein and calories. 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.
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