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The former can be managed by artificial ventilation, and the latter by gastrostomy or other artificial feeding, unless the patient has recurrent aspiration pneumonia. been made to provide accurate and complete information, CMS does not guarantee that there are no errors in the information displayed Coverage Indications, Limitations, and/or Medical Necessity. 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. The population for key question 3 will only include patients with a diagnosis of protein-energy malnutrition. (1 and 2 should be present, factors from 3 will lend supporting documentation. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or Neurologic disease (CVA, ALS, MS, Parkinsons), Refractory severe autoimmune disease (e.g. endstream endobj 647 0 obj <>/Metadata 45 0 R/Pages 44 0 R/StructTreeRoot 47 0 R/Type/Catalog/ViewerPreferences<>>> endobj 648 0 obj <>/ExtGState<>/Font<>/ProcSet[/PDF/Text/ImageC]/Properties<>>>/XObject<>>>/Rotate 0/StructParents 0/TrimBox[0.0 0.0 612.0 792.0]/Type/Page>> endobj 649 0 obj <> endobj 650 0 obj <> endobj 651 0 obj [/ICCBased 686 0 R] endobj 652 0 obj [/ICCBased 687 0 R] endobj 653 0 obj <> endobj 654 0 obj <> endobj 655 0 obj <> endobj 656 0 obj <>stream 0000008839 00000 n Copyright © 2022, the American Hospital Association, Chicago, Illinois. Physicians and hospice care: attitudes, knowledge, and referrals. All Rights Reserved (or such other date of publication of CPT). 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 . 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.Example:Systemic hypertension; coronary artery disease; diabetes mellitus; history of cardiotoxic drug therapy or alcohol abuse; personal history of rheumatic fever; family history of cardiomyopathy.Stage BPatients 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.Example:Left ventricular hypertrophy or fibrosis; left ventricular dilatation or hypocontractility; asymptomatic valvular heart disease; previous myocardial infarction.Stage CPatients who have current or prior symptoms of HF associated with underlying structural heart disease.Example:Dyspnea or fatigue due to left ventricular systolic dysfunction; asymptomatic patients who are undergoing treatment for prior symptoms of HF.Stage DPatients with advanced structural heart disease and marked symptoms of HF at rest despite maximal medical therapy and who require specialized interventions.Example: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.Karnofsky Performance Scale (KPS)The Karnofsky Performance Scale Index allows patients to be classified as to their functional impairment. 2001;104:2996-3007. Alzheimer's disease and other progressive dementias are life-altering and eventually fatal conditions for which curative therapy is not available. Requires considerable assistance and frequent medical care. 0000008742 00000 n 2003;20: 41-51.Ogle K, Mavis B, Wang T. Physicians and hospice care: attitudes, knowledge and referrals. DATE (05/31/2018): At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. CMS believes that the Internet is an effective method to share LCDs that Medicare contractors develop. Analysis of Evidence (Rationale for Determination), LCD - Hospice - Determining Terminal Status (L33393). 0000015606 00000 n Stage 5 (Early Dementia) Moderately severe cognitive decline. + Progressive inanition is documented by several measures such as 10% body weight loss, decreased albumin, and dysphagia leading to aspiration, among others. Baker D, Chin M, Cinquigrani M, et al. 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. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely. As used herein, "you" and "your" refer to you and any organization on behalf of which you are acting. ), HIV DiseasePatients will be considered to be in the terminal stage of their illness (life expectancy of six months or less) if they meet the following criteria. The former can be managed by artificial ventilation, and the latter by gastrostomy or other artificial feeding, unless the patient has recurrent aspiration pneumonia. Marasmus, or PEM without edema, is . 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. Federal government websites often end in .gov or .mil. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be . presented in the material do not necessarily represent the views of the AHA. It is rare occurrence in the U.S. E41 is used to report nutritional marasmus, a form of malnutrition characterized by consumption of . Dyspnea or fatigue due to left ventricular systolic dysfunction; asymptomatic patients who are undergoing treatment for prior symptoms of HF. Note that two of the disease specific guidelines (HIV Disease, Stroke and Coma) establish a lower qualifying KPS or PPS. The lower the Karnofsky score, the worse the survival for most serious illnesses.KARNOFSKY PERFORMANCE STATUS SCALE DEFINITIONS RATING (%) CRITERIA. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials. Patients who have current or prior symptoms of HF associated with underlying structural heart disease. 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. THE INFORMATION, PRODUCT, OR PROCESSES DISCLOSED HEREIN. Applicable FARS\DFARS Restrictions Apply to Government Use. The CMS.gov Web site currently does not fully support browsers with 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. 0000004098 00000 n Studies enrolling individuals with planned admissions (e.g. An asterisk (*) indicates a Unspecified severe protein-calorie malnutrition. Some patients may not meet these guidelines, yet still have a life expectancy of six months or less. Baseline data may be established on admission to hospice or by using existing information from records. Please visit the, Progression of disease as documented by worsening clinical status, symptoms, signs and laboratory results. They are examples of findings that generally connote a poor prognosis. 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. of every MCD page. patients who should be at complete rest, confined to bed or chair; any physical activity brings on discomfort and symptoms occur at rest. 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. 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. (1 and 2 should be present. 0000017875 00000 n Lose basic psychomotor skills, e.g., ability to walk, sitting and head control. 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. 0000005794 00000 n Able to carry on normal activity and to work; no special care needed. 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. Secondary Criteria Notes . Note: 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.Non-Cancer DiagnosesAmyotrophic Lateral SclerosisGeneral Considerations: 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).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.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.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. 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. All Rights Reserved (or such other date of publication of CPT). 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. 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. ): Patients will be considered to be in the terminal stage of their illness (life expectancy of six months or less) if they meet the following criteria. CMS and its products and services are not endorsed by the AHA or any of its affiliates. CMS and its products and services are not endorsed by the AHA or any of its affiliates. Please note that if you choose to continue without enabling "JavaScript" certain functionalities on this website may not be available. CPT codes, descriptions and other data only are copyright 2022 American Medical Association. The document is broken into multiple sections. 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 < 25 cells/mcl or persistent (2 or more assays at least one month apart) viral load >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 less than or equal to 50%. Medicare program. 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. 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. This LCD outlines coverage for hospice as indicated in the coverage and indications section. Factors from 3 will add supporting documentation. not endorsed by the AHA or any of its affiliates. (1 and 2 should be present. These situations are obvious. 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. Revision Explanation: Annual review no changes were made. 1991;155:384-387.Reisberg B. ElderCare online. However, no single variable deteriorates at a uniform rate in all patients. Similarly, . No subjective complaints of memory deficit. ; Supratentorial: greater than or equal to 50 ml. Laboratory tests in protein-calorie malnutrition Lancet. CMS and its products and services are 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. Flattening of affect and withdrawal from challenging situations occur. patient declines further disease directed therapyNote: Certain cancers with poor prognoses (e.g. An educated person may have difficulty counting back from 40 by 4s or from 20 by 2s. and the State Children's Health Insurance Programs, contracts with certain organizations to assist in the administration of the Stroke or coma. ), 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. ), 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. Will be largely unaware of all recent events and experiences in their lives. Progressive malnutrition, muscle wasting with dec. strength, ongoing alcoholism (>80 gm . such information, product, or processes will not infringe on privately owned rights. special, incidental, or consequential damages arising out of the use of such information, product, or process. 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.