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. Applicable Federal Acquisition Regulation Clauses (FARS)/Department of Defense Federal Acquisition Regulation supplement (DFARS) Restrictions Apply to Government Use. All verbal abilities are lost. The guidelines for LCD development are provided in Chapter 13 of the Medicare Program Integrity Manual. Thus the overall rate of decline in each patient is fairly constant and predictable, unlike many other non-cancer diseases. ), Liver DiseasePatients 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. 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. Denial is dominant defense mechanism. Proposed LCD document IDs begin with the letters "DL" (e.g., DL12345). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. Dyspnea or fatigue due to left ventricular systolic dysfunction; asymptomatic patients who are undergoing treatment for prior symptoms of HF. 0000008630 00000 n undergoing non-emergent elective procedures), patients receiving or who have received hospice services, or pregnant women will not be considered for inclusion in this report. Experiences urinary and fecal incontinence. CPT codes, descriptions and other data only are copyright 2022 American Medical Association. Reproduced with permission. ), 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. End User Point and Click Amendment: 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. t'h0&@,41%;j4aJEG>wJ4RA0^c 7500 Security Boulevard, Baltimore, MD 21244. 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. The population for key question 3 will only include patients with a diagnosis of protein-energy malnutrition. small cell lung cancer, brain cancer and pancreatic cancer) may be hospice eligible without fulfilling the other criteria in this section.Section II: Non-Cancer DiagnosesA. descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work 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. 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 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 50%. 0000039330 00000 n on this web site. The A.S.P.E.N. PDF Hospice Eligibility Criteria - University of New Mexico It does not mean, however, that meeting the guideline is obligatory. E46 - Unspecified protein calorie malnutrition E64 - Sequelae of protein calorie malnutrition. descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work Therefore, multiple clinical parameters are required to judge the progression of ALS. 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. %PDF-1.4 % 26 Because the goal of dietary supplements is to provide adequate energy and protein. Baseline data may be established on admission to hospice or by using existing information from records. ): G. 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 or 3 should be present. The Centers for Medicare & Medicaid Services (CMS), the federal agency responsible for administration of the Medicare, Medicaid 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. 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. Right heart failure (RHF) secondary to pulmonary disease (Cor pulmonale) (e.g., not secondary to left heart disease or valvulopathy). At the time of initial certification or recertification for hospice, the patient is or has been already optimally treated for heart disease or is not a candidate for a surgical procedure or has declined a procedure. Progressive decline in Functional Assessment Staging (FAST) for dementia (from 7A on the FAST). (Class IV patients with heart disease have an inability to carry on any physical activity without discomfort. Stage 6 (Middle Dementia) Severe cognitive decline.May occasionally forget the name of the spouse upon whom they are entirely dependent for survival. 0000005794 00000 n 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. ): 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. . Progressive malnutrition, muscle wasting with dec. strength, ongoing alcoholism (>80 gm . The views and/or positions presented in the material do not necessarily represent the views of the AHA. There has been no change in coverage with this LCD revision. 0000160163 00000 n For principle diagnoses in which severe protein-calorie malnutrition could be listed as a MCC, there must be documentation demonstrating additional The criteria refer to patients with various forms of advanced pulmonary disease who eventually follow a final common pathway for end stage pulmonary disease. Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, THE INFORMATION, PRODUCT, OR PROCESSES DISCLOSED HEREIN. Frequently there is no speech at all - only grunting. 0000014923 00000 n patients with marked limitation of activity; they are comfortable only at rest. Patient should demonstrate critically impaired breathing capacity. Please visit the, Progression of disease as documented by worsening clinical status, symptoms, signs and laboratory results. PMID . The AMA does not directly or indirectly practice medicine or dispense medical services. In critically ill patients, these alterations can. Although coding guidelines state that only one of these criteria needs to be met . Mild to moderate anxiety accompanies symptoms. Measurement of quality of life in patients with lung cancer in multicenter trials of new therapies. The AMA does not directly or indirectly practice medicine or dispense medical services. and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only Patient declines further disease directed therapy. Able to carry on normal activity and to work; no special care needed. Another option is to use the Download button at the top right of the document view pages (for certain document types). The use of the Karnofsky Performance Scale in determining outcomes and risk in geriatric outpatients. A: Determining when to query for a malnutrition diagnosis can be very tricky. AJ Hospice & Palliative Care, 2003; 20; 41-51. J Palliative Medicine. Applicable FARS/HHSARS apply. 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. There are multiple ways to create a PDF of a document that you are currently viewing. P rint Checklist: Documenting malnutrition (E41 and E43) This checklist is intended to provide healthcare providers with a reference for use when responding to medical documentation requests for services rendered and hospital admissions to treat malnutrition. Use is limited to use in Medicare, Medicaid or other programs administered by the Centers for Medicare and Medicaid Services (CMS). LCDs outline how the contractor will review claims to ensure that the services provided meet Medicare coverage requirements. By clicking below on the button labeled "I accept", you hereby acknowledge that you have read, understood and agreed to all terms and conditions set forth in this agreement. The scope of this license is determined by the AMA, the copyright holder. Despite the prevalence of protein-calorie malnutrition (PCM) in acute-care hospitals and long-term care centers, a national and global consensus on nutrition screening and malnutrition diagnosis is lacking. The amendment clarified that the certification is based on a clinical judgment regarding the usual course of a terminal illness, and recognizes the fact that making medical prognostications of life expectancy is not always exact. Able to carry on normal activity; minor signs or symptoms of disease. 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.IndicationsA 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 Part III will establish the necessary expectancy.Part I. Before an LCD becomes final, the MAC publishes Proposed LCDs, which include a public comment period. Right heart failure (RHF) secondary to pulmonary disease (Cor pulmonale) (e.g., not secondary to left heart disease or valvulopathy). There is no regulation precluding patients on dialysis from electing Hospice care. Golden, AM. The brain appears to no longer be able to tell the body what to do. Decline in clinical status guidelines 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. 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. ALS tends to progress in a linear fashion over time. 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. 0000040550 00000 n 0000037955 00000 n While every effort has You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials. "JavaScript" disabled. 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. xref 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 . Another option is to use the Download button at the top right of the document view pages (for certain document types). At the New York University Medical Center's Aging and Dementia Research Center, Barry Reisberg, MD and colleagues have developed the Functional Assessment Staging (FAST) scale, which allows professionals and caregivers to chart the decline of people with Alzheimer's disease. This LCD outlines coverage for hospice as indicated in the coverage and indications section. 0000011855 00000 n HUjI}iuU!v` "Y]I!T 3:NU^#={6: K]Sdl*B!XA-m2{gcm8n W)' fvtkW~e,y&2%!98kzb .