Although guidelines applicable to certain disease categories are included, this LCD is applicable to all hospice patients. 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. (1 and 2 should be present. of every MCD page. 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. There is no regulation precluding patients on dialysis from electing Hospice care. The patient is classified as New York Heart Association (NYHA) Class IV and may have significant symptoms of heart failure or angina at rest. They are listed in order of their likelihood to predict poor survival, the most predictive first and the least predictive last. (1 and 2 should be present, factors from 3 will lend supporting documentation. Cancer. Lose basic psychomotor skills, e.g., ability to walk, sitting and head control. The Global Malnutrition Composite Score (GMCS) electronic clinical quality measure is comprised of four components reflecting inpatient malnutrition identification and care. An official website of the United States government. The AMA does not directly or indirectly practice medicine or dispense medical services. 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; 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. The brain appears to no longer be able to tell the body what to do. Made a technical update to this LCD to remove the empty Coding Information fields. It is intended to be used to identify any Medicare beneficiary whose current clinical status and anticipated progression of disease is more likely than not to result in a life expectancy of six months or less.Clinical variables with general applicability without regard to diagnosis, as well as clinical variables applicable to a limited number of specific diagnoses, are provided. 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. 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. If your session expires, you will lose all items in your basket and any active searches. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material. Use is limited to use in Medicare, Medicaid or other programs administered by the Centers for Medicare and Medicaid Services (CMS). Current Dental Terminology © 2022 American Dental Association. 0000014923 00000 n No specific number of variables must be met, but fewer of those listed first (more predictive) and more of those listed last (least predictive) would be expected to predict longevity of six months or less. This is the American ICD-10-CM version of E43 - other international versions of ICD-10 E43 may differ. 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. 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. Progressive decline in Functional Assessment Staging (FAST) for dementia (from 7A on the FAST). ), 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. The population for key question 3 will only include patients with a diagnosis of protein-energy malnutrition. License to use CDT for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. 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. Please note that if you choose to continue without enabling "JavaScript" certain functionalities on this website may not be available. 0000017107 00000 n without the written consent of the AHA. Large anterior infarcts with both cortical and subcortical involvement. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. If you are experiencing any technical issues related to the search, selecting the 'OK' button to reset the search data should resolve your issues. End User License Agreement: Surface area of involvement of hemorrhage 30% of cerebrum; Obstructive hydrocephalus in patient who declines, or is not a candidate for, ventriculoperitoneal shunt. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. "JavaScript" disabled. Healthcare providers retain responsibility to submit complete and accurate. 0000008630 00000 n documentation. CEA, PSA); Progressively decreasing or increasing serum sodium or increasing serum potassium. for diabetics); or < 15cc/min (< 20cc/min for diabetics) with comorbidity of congestive heart failure. Although guidelines applicable to certain disease categories are included, this policy is applicable to all hospice patients. Dysphagia severe enough to prevent the patient from receiving food and fluids necessary to sustain life, in a patient who declines or does not receive artificial nutrition and hydration. Therefore, multiple clinical parameters are required to judge the progression of ALS. Other clinical variables not on this list may support a six-month or less life expectancy. 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. Unable to dress without assistance. 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. ), Hypoxemia at rest on room air, as evidenced by pO2 55 mmHg; or oxygen saturation 88%, determined either by arterial blood gases or oxygen saturation monitors; (These values may be obtained from recent hospital records.) Protein-Energy Malnutrition / diagnosis Serum Albumin / analysis Substances Amino Acids . (Class IV patients with heart disease have an inability to carry on any physical activity. recommending their use. See Part III for disease specific guidelines to be used with these baseline guidelines. 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. Christakis N, Lamont E. Extent and determinants of error in doctors prognoses in terminally ill patients: prospective cohort study. All rights reserved. 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 NYHA Functional Classification for Congestive Heart FailureThe New York Heart Association (NYHA) Functional Classification provides a simple way of classifying heart disease (originally cardiac failure). ; Supratentorial: greater than or equal to 50 ml. 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. 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.However, the amendment regarding the physician's clinical judgment does not negate the fact that there must be a basis for a certification. 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. The American Hospital Association ("the AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. 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. Consistent with Change Request 10901, all coding information, National coverage provisions, and Associated Information (Documentation Requirements, Utilization Guidelines) have been removed from the LCD and placed in the related Billing and Coding Article, A52830. 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. K. Ogle, B. Mavis, T. Wang. Patients with dementia or Alzheimer's are eligible for hospice care when they show all of the following characteristics: 1. Each type may be classified as acute or chronic. Analysis of Evidence (Rationale for Determination), LCD - Hospice - Determining Terminal Status (L33393). 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. presented in the material do not necessarily represent the views of the AHA. 1993;24:320- 327.Doyle D, Hanks G, Cherny N and Calman K. Oxford textbook of palliative medicine. Therefore, multiple clinical parameters are required to judge the progression of ALS. Protein calorie malnutrition is a type of undernutrition. Disease with distant metastases at presentation ORB. LCDs outline how the contractor will review claims to ensure that the services provided meet Medicare coverage requirements. ), 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. Factors from 4 will lend supporting documentation.). If any physical activity is undertaken, discomfort is increased.) No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be 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. 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. CEA, PSA); Progressively decreasing or increasing serum sodium or increasing serum potassium. Baseline data may be established on admission to hospice or by using existing information from records. The views and/or positions presented in the material do not necessarily represent the views of the AHA. Unable to work; able to live at home and care for most personal needs; varying amount of assistance needed. All Rights Reserved (or such other date of publication of CPT). 0000060832 00000 n While these characteristics are assessed along a continuum, rather than as discrete variables, they are useful in formulating and documenting a diagnosis of malnutrition. 0000038995 00000 n Revision Explanation: Annual review, no changes made. Medicare contractors are required to develop and disseminate Local Coverage Determinations (LCDs). recipient email address(es) you enter. 646 0 obj <> endobj In no event shall CMS be liable for direct, indirect, authorized with an express license from the American Hospital Association. copied without the express written consent of the AHA. 0000061858 00000 n Please visit the, Progression of disease as documented by worsening clinical status, symptoms, signs and laboratory results. Applicable FARS\DFARS Restrictions Apply to Government Use. There has been no change in coverage with this LCD revision. Sign up to get the latest information about your choice of CMS topics in your inbox. There are multiple ways to create a PDF of a document that you are currently viewing. However, the continuation of dialysis will significantly alter a patients prognosis, and thus potentially impact that individuals eligibility. (1 and 2 should be present. Revision Explanation: Annual review no changes made. General Guidelines:Documentation certifying terminal status must contain enough information to support terminal status upon review. 0000002894 00000 n Flattening of affect and withdrawal from challenging situations occur. Proposed LCD document IDs begin with the letters "DL" (e.g., DL12345). Applicable Federal Acquisition Regulation Clauses (FARS)/Department of Defense Federal Acquisition Regulation supplement (DFARS) Restrictions Apply to Government Use. Before an LCD becomes final, the MAC publishes Proposed LCDs, which include a public comment period. CMS believes that the Internet is an effective method to share LCDs that Medicare contractors develop. (Optimally treated means that patients who are not on vasodilators have a medical reason for refusing these drugs, e.g., hypotension or renal disease.). 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 Stage 3 (Early Confusional)Mild cognitive decline. Decline in systolic blood pressure to below 90 or progressive postural hypotension, Venous, arterial or lymphatic obstruction due to local progression or metastatic disease, Laboratory (When available. THE INFORMATION, PRODUCT, OR PROCESSES DISCLOSED HEREIN. It places patients in one of four categories, based on how much they are limited during physical activity:Class I: patients with no limitation of activities; they suffer no symptoms from ordinary activities.Class II: patients with slight, mild limitation of activity; they are comfortable with rest or with mild exertion.Class III: patients with marked limitation of activity; they are comfortable only at rest.Class IV: patients who should be at complete rest, confined to bed or chair; any physical activity brings on discomfort and symptoms occur at rest.Palliative Performance ScaleThe Palliative Performance Scale (PPS) is a modification of the Karnofsky Performance Scale intended for evaluating patients requiring palliative care. accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the Disease Specific GuidelinesNote: These guidelines are to be used in conjunction with the Non-disease specific baseline guidelines described in Part II.Cancer Diagnoses. R7Revision Effective: 01/21/2021Revision Explanation: Updated values to the liver and renal disease section based on KDIGO information in the general associated information section and corrected formatting were needed. All Rights Reserved. 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). Patient should demonstrate both rapid progression of ALS and critical nutritional impairment. HMn1>.`Ax! Use of CDT is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS).