Applications are available at the AMA Web site, http://www.ama-assn.org/go/cpt. Part II. Right heart failure (RHF) secondary to pulmonary disease (Cor pulmonale) (e.g., not secondary to left heart disease or valvulopathy). While most healthcare facilities still follow the previous ASPEN criteria, in 2018, ASPEN joined with the . 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. Lab testing is not required to establish hospice eligibility. Secondary Criteria Notes . Protein-Energy Malnutrition / diagnosis Serum Albumin / analysis Substances Amino Acids . SERUM PROTEIN Progression of disease as documented by worsening clinical status, symptoms, signs and laboratory results. Dyspnea with increasing respiratory rate; Nausea/vomiting poorly responsive to treatment; Pain requiring increasing doses of major analgesics more than briefly. 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 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. Progressive decline in Functional Assessment Staging (FAST) for dementia (from 7A on the FAST). CDT is a trademark of the ADA. 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. The views and/or positions presented in the material do not necessarily represent the views of the AHA. Personality and emotional changes occur. ): 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. 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. J Palliative Medicine 2002; 5; 85-92. Please do not use this feature to contact CMS. been made to provide accurate and complete information, CMS does not guarantee that there are no errors in the information displayed ), (1 and either 2 or 3 should be present. (1 and 2 should be present. 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. 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. Able to carry on normal activity; minor signs or symptoms of disease. Proposed LCD document IDs begin with the letters "DL" (e.g., DL12345). Hepatic encephalopathy, refractory to treatment, or patient non-compliant; Recurrent variceal bleeding, despite intensive therapy. If a patient improves 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. Neurologic disease (CVA, ALS, MS, Parkinsons), Refractory severe autoimmune disease (e.g. 0000011336 00000 n 0000011855 00000 n The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. All Rights Reserved (or such other date of publication of CPT). These materials contain Current Dental Terminology (CDTTM), copyright© 2022 American Dental Association (ADA). 0000015606 00000 n As each patient is unique, there are patients for whom a particular guideline does not match. An educated person may have difficulty counting back from 40 by 4s or from 20 by 2s. Please note that codes (CPT/HCPCS and ICD-10) have moved from LCDs to Billing & Coding Articles. 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". Instructions for enabling "JavaScript" can be found here. patients with slight, mild limitation of activity; they are comfortable with rest or with mild exertion. Although ALS usually presents in a localized anatomical area, the location of initial presentation does not correlate with survival time. 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 criteria refer to patients with various forms of advanced pulmonary disease who eventually follow a final common pathway for end stage pulmonary disease. N. Christakis, E. Lamont. The Social Security Act, Sections 1869(f)(2)(B) and 1862(l)(5)(D) define LCDs and provide information on the process. without the written consent of the AHA. Protein calorie malnutrition, nutritional intervention and personalized cancer care Authors Anju Gangadharan 1 , Sung Eun Choi 2 , Ahmed Hassan 1 , Nehad M Ayoub 3 , Gina Durante 4 , Sakshi Balwani 1 , Young Hee Kim 4 , Andrew Pecora 5 , Andre Goy 5 , K Stephen Suh 1 Affiliations Please enable "JavaScript" and revisit this page or proceed with browsing CMS.gov with small cell lung cancer, brain cancer and pancreatic cancer) may be hospice eligible without fulfilling the other criteria in this section. 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. Stroke or coma. (This value may be obtained from recent [within 3 months] hospital records.). 0000016419 00000 n 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. 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; Clear-cut deficit on careful clinical interview. These should be documented in the clinical record. The use of the New York heart association's classification of cardiovascular disease as part of the patient's complete problem list. Stage 4 (Late Confusional)Moderate cognitive decline. 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. 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. 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. Surface area of involvement of hemorrhage 30% of cerebrum; Obstructive hydrocephalus in patient who declines, or is not a candidate for, ventriculoperitoneal shunt. Unable to dress without assistance. 7500 Security Boulevard, Baltimore, MD 21244. Circulation. Cancer. Part III. The responsibility for the content of this file/product is with CMS and no endorsement by the AMA is intended or implied. The 2023 edition of ICD-10-CM E43 became effective on October 1, 2022. Similarly, . You acknowledge that the ADA holds all copyright, trademark and other rights in CDT. without the written consent of the AHA. 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. 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. This LCD describes guidelines to be used by National Government Services (NGS) in reviewing hospice claims and by hospice providers to determine eligibility of beneficiaries for hospice benefits. Medicare contractors are required to develop and disseminate Local Coverage Determinations (LCDs). Factors from 3 will add supporting documentation. 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. 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. Neither the United States Government nor its employees represent that use of Current Dental Terminology © 2022 American Dental Association. The document is broken into multiple sections. THE INFORMATION, PRODUCT, OR PROCESSES DISCLOSED HEREIN. descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work Accessed 01/16/2008.Schag CC, Heinrich RL, Ganz, PA. Karnofsky performance status revisited: Reliability, validity, and guidelines. - 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. 2001;104:2996-3007. All rights reserved. Unintentional progressive weight loss of greater than 10% of body weight over the preceding six months. Surface area of involvement of hemorrhage greater than or equal to 30% of cerebrum; Midline shift greater than or equal to 1.5 cm. 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. 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 of every MCD page. However, the amendment regarding the physician's clinical judgment does not negate the fact that there must be a basis for a certification. R8Revision Effective: 05/06/2021Revision Explanation: Corrected typo in the associated information section under acute renal failure. Symptoms Include a number of symptoms, including nausea and vomiting, dyspnea, persisting cough, fatigue, decreased cognition, diarrhea, and progressive pain Signs Pulmonary Disease. 0000008630 00000 n 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. Factors from 4 will lend supporting documentation. Factors from 3 will add supporting documentation. Incontinent of urine, requires assistance toileting and feeding. All Rights Reserved (or such other date of publication of CPT). 0000003910 00000 n 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. Speech ability declines to about a half-dozen intelligible words. The page could not be loaded. Oxford University Press. Disease with distant metastases at presentation ORB. ), 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. 0000025584 00000 n FAST scale. http://www.ed-online.net\. 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.'' (1 and 2 should be present; factors from 3 will add supporting documentation. Also, the lack of certain documentation elements such as a tissue diagnosis for cancer will not create non-eligibility for the hospice benefit, but does necessitate other supportive documentation.Documentation submitted may include information from periods of time that fall outside the billing period currently under review. They require no assistance with toileting and eating, but may have some difficulty choosing the proper clothing to wear. License to use CPT for any use not authorized herein must be obtained through the AMA, CPT Intellectual Property Services, AMA Plaza 330 N. Wabash Ave., Suite 39300, Chicago, IL 60611-5885. 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. Normal no complaints; no evidence of disease. 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. No subjective complaints of memory deficit. 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 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. 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. The views and/or positions No fee schedules, basic unit, relative values or related listings are included in CPT. Our audit covered $3.4 billion in Medicare payments for 224,175 claims with a discharge date in fiscal year (FY) 2016 or 2017 that contained a severe malnutrition diagnosis code and for which removing the diagnosis code changed the diagnosis-related group (DRG). Disabled; requires special care and assistance. (1 and 2 should be present, factors from 3 will lend supporting documentation. 0000012375 00000 n Instructions for enabling "JavaScript" can be found here. Please review and accept the agreements in order to view Medicare Coverage documents, which may include licensed information and codes. The score can help determine which patients can be managed in the home and which should be admitted to a hospice unit. 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. 1999;22(6):385-90.Lamont E, Christakis N. Prognostic disclosure to patients with cancer near the end of life. "JavaScript" disabled. Christakis N, Lamont E. Extent and determinants of error in doctors prognoses in terminally ill patients: prospective cohort study. 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. As used herein, "you" and "your" refer to you and any organization on behalf of which you are acting. CEA, PSA); Progressively decreasing or increasing serum sodium or increasing serum potassium. All rights reserved. If you would like to extend your session, you may select the Continue Button. CMS and its products and services are 0000001970 00000 n The population for key question 3 will only include patients with a diagnosis of protein-energy malnutrition. There are multiple ways to create a PDF of a document that you are currently viewing. Coverage for these patients may be approved if documentation otherwise supporting a less than six-month life expectancy is provided. recommending their use. End Users do not act for or on behalf of the CMS. Current Dental Terminology © 2022 American Dental Association. 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 Tracking Sheet modal can be closed and re-opened when viewing a Proposed LCD. "JavaScript" disabled. 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. 0000003355 00000 n (1 and 2 should be present. All rights reserved. (1 and 2 should be present; factors from 3 will lend supporting documentation. The criteria refer to patients with various forms of advanced pulmonary disease who eventually follow a final common pathway for end stage pulmonary disease. 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". Stage 5 (Early Dementia) Moderately severe cognitive decline. Large anterior infarcts with both cortical and subcortical involvement. While it is true that there is not a strict six month limit on the Hospice benefit, the underlying precept is that the beneficiary must have a prognosis of six months or less, if the illness runs its normal course. patients who should be at complete rest, confined to bed or chair; any physical activity brings on discomfort and symptoms occur at rest. accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the Denial begins to become manifest in patient. 26 Because the goal of dietary supplements is to provide adequate energy and protein. While not necessarily a contraindication to Hospice care, the decision to institute either artificial ventilation or artificial feeding may significantly alter six month prognosis. 0000006339 00000 n The scope of this license is determined by the AMA, the copyright holder. No objective deficits in employment or social situations. Other clinical variables not on this list may support a six-month or less life expectancy. Physiologic impairment of functional status as demonstrated by: Karnofsky Performance Status (KPS) or Palliative Performance Score (PPS) < 70%. CPT codes, descriptions and other data only are copyright 2022 American Medical Association. ): Patients awaiting liver transplant who otherwise fit the above criteria may be certified for the Medicare hospice benefit, but if a donor organ is procured, the patient should be discharged from hospice.F. Progression of disease differs markedly from patient to patient. 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 It was developed in British Columbia, Canada. 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. See Part III for disease specific guidelines to be used with these baseline guidelines. No fee schedules, basic unit, relative values or related listings are included in CPT. 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. These materials contain Current Dental Terminology (CDTTM), copyright© 2022 American Dental Association (ADA). 2002;5:85-92.O'Toole DM. All Rights Reserved. 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. End User License Agreement: Although guidelines applicable to certain disease categories are included, this LCD is applicable to all hospice patients. patients with marked limitation of activity; they are comfortable only at rest. + History of increasing ER visits, hospitalizations, or physician visits related to the hospice primary diagnosis prior to election of the hospice benefit. Unable to care for self; requires equivalent of institutional or hospital care; disease may be progressing rapidly. Ogle K, Mavis B, Wang T. Hospice and primary care physicians: attitudes, knowledge, and barriers. CPT codes, descriptions and other data only are copyright 2022 American Medical Association. Hospice Eligibility Criteria Patient has a terminal illness with a life . Evaluating cancer patients for rehabilitation potential. Applicable FARS\DFARS Restrictions Apply to Government Use. 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. Dysphagia leading to recurrent aspiration and/or inadequate oral intake documented by decreasing food portion consumption. 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. Protein-calorie malnutrition (PCM) occurs when a child doesn't eat enough proteins and calories to meet nutritional needs. Note that two of the disease specific guidelines (HIV Disease, Stroke and Coma) establish a lower qualifying KPS or PPS. 0000014780 00000 n %%EOF The FAST scale has 16 stages and sub-stages: Personal awareness of some functional decline. General Guidelines:Documentation certifying terminal status must contain enough information to support terminal status upon review. 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. Nausea/vomiting poorly responsive to treatment. 0000037874 00000 n Skip to main content Skip to navigation Skip to navigation. Language quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. Please review and accept the agreements in order to view Medicare Coverage documents, which may include licensed information and codes. such information, product, or processes will not infringe on privately owned rights. In critically ill patients, these alterations can. Adult Malnutrition or Severe Protein Calorie Malnutrition PPS is < 40% Dependent for > 2 ADL's MI < 22 Weight loss (> 10% in 6 months, > 5% in 3 months) Hepatorenal syndrome Loss of muscle mass, subcutaneous fat Patient/family/DPOA wants hospice care and is refusing curative treatment Infections (aspiration pneumonia, urinary tract 0000002310 00000 n End User Point and Click Amendment: You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials. 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. THE INFORMATION, PRODUCT, OR PROCESSES DISCLOSED HEREIN. ), Renal DiseasePatients will be considered to be in the terminal stage of renal disease (life expectancy of six months or less) if they meet the following criteria.Acute Renal Failure (1 and either 2, 3 or 4 should be present. 0000012920 00000 n 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. AJ Hospice & Palliative Care. A52830 - Billing and Coding: Hospice: Determining Terminal Status. Very sick; hospital admission necessary; active supportive treatment necessary. CMS believes that the Internet is an effective method to share LCDs that Medicare contractors develop. Sign up to get the latest information about your choice of CMS topics in your inbox. required field. Dr Reisberg has also shown that the decline typical of Alzheimer's disease is the flip side of normal skill acquisition by infants, children, and young adults: Available from ElderCare Online http://www.ec-online.net/ Barry Reisberg, MD 1984. 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. on this web site. Requires occasional assistance, but is able to care for most of his personal needs. May have difficulty counting from 10, both backward and sometimes forward. British Medical Journal. Some patients may not meet these guidelines, yet still have a life expectancy of 6 months or less. 0000040523 00000 n 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.