Disease with distant metastases at presentation ORB. Factors from 3 will add supporting documentation. All billing and coding information was previously moved to the related Billing and Coding Article, A52830. The AMA does not directly or indirectly practice medicine or dispense medical services. The guidelines for LCD development are provided in Chapter 13 of the Medicare Program Integrity Manual. @7Eq p[3gXsm!t;ON-:5,lX`9^n:myuT.sf~RG}|^no\x XP\w( 0000008075 00000 n If other clinical indicators of decline not listed in this policy such as psychological and spiritual factors form the basis for certifying terminal status, they should be documented as well. If your session expires, you will lose all items in your basket and any active searches. The AMA is a third party beneficiary to this Agreement. )ndgM`.K3{daYpz:=~F~c~Cm& m& m& m& m#=#)XOz 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. An educated person may have difficulty counting back from 40 by 4s or from 20 by 2s. Nausea/vomiting poorly responsive to treatment. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials. The AMA is a third party beneficiary to this Agreement. Progression of disease as documented by worsening clinical status, symptoms, signs and laboratory results. Surface area of involvement of hemorrhage 30% of cerebrum; Obstructive hydrocephalus in patient who declines, or is not a candidate for, ventriculoperitoneal shunt. THE UNITED STATES GOVERNMENT AND ITS EMPLOYEES ARE NOT LIABLE FOR ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN 0000002894 00000 n The CMS.gov Web site currently does not fully support browsers with FAST scale. 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. Patients with congestive heart failure or angina should meet the criteria for the New York Heart Association (NYHA) Class IV. Dyspnea or fatigue due to left ventricular systolic dysfunction; asymptomatic patients who are undergoing treatment for prior symptoms of HF. Additionally, marasmus can precede kwashiorkor. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not (Documentation of serial decrease of FEV1>40 ml/year is objective evidence for disease progression, but is not necessary to obtain. The Social Security Act, Sections 1869(f)(2)(B) and 1862(l)(5)(D) define LCDs and provide information on the process. Reproduced with permission. THE INFORMATION, PRODUCT, OR PROCESSES DISCLOSED HEREIN. t'h0&@,41%;j4aJEG>wJ4RA0^c <]/Prev 527120/XRefStm 1970>> 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. Karnofsky Performance Status (KPS) or Palliative Performance Scale (PPS) of < 40% . AHA copyrighted materials including the UB‐04 codes and The former can be managed by artificial ventilation, and the latter by gastrostomy or other artificial feeding, unless the patient has recurrent aspiration pneumonia. 26 Because the goal of dietary supplements is to provide adequate energy and protein. Manifestations in more than one of the following areas: Objective evidence of memory deficit obtained only with an intensive interview. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT. Instructions for enabling "JavaScript" can be found here. Hospice Eligibility Criteria Patient has a terminal illness with a life . The score can help determine which patients can be managed in the home and which should be admitted to a hospice unit. routine or continuous home or inpatient, respite, or general. 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. 0000003910 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. been made to provide accurate and complete information, CMS does not guarantee that there are no errors in the information displayed Factors from 5 will lend supporting documentation. Normal no complaints; no evidence of disease. Recurrent or intractable infections such as pneumonia, sepsis or upper urinary tract. ge"^WOgr |___W+ tpIht=hozGC8 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. (Optimally treated means that patients who are not on vasodilators have a medical reason for refusing these drugs, e.g., hypotension or renal disease.). 01/11/2021: At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. 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 page displays your requested Local Coverage Determination (LCD). In no event shall CMS be liable for direct, indirect, At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. Other clinical variables not on this list may support a six-month or less life expectancy. Thus the overall rate of decline in each patient is fairly constant and predictable, unlike many other non-cancer diseases. Severe chronic lung disease as documented by both a and b: Disabling dyspnea at rest, poorly or unresponsive to bronchodilators, resulting in decreased functional capacity, e.g., bed to chair existence, fatigue, and cough: (Documentation of Forced Expiratory Volume in One Second (FEV1), after bronchodilator, less than 30% of predicted is objective evidence for disabling dyspnea, but is not necessary to obtain. If you would like to extend your session, you may select the Continue Button. 1991;46:M139-M144.de Haan R, Aaronson A, Limburg M, et al. 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. (1 and 2 should be present. For this reason, the history of the rate of progression in individual patients is important to obtain to predict prognosis. 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. The Tracking Sheet modal can be closed and re-opened when viewing a Proposed LCD. Speech ability declines to about a half-dozen intelligible words. Protein-Energy Malnutrition / diagnosis Serum Albumin / analysis Substances Amino Acids . While not necessarily a contraindication to Hospice Care, the decision to institute either artificial ventilation or artificial feeding will significantly alter six-month prognosis. 0000029167 00000 n patient declines further disease directed therapyNote: Certain cancers with poor prognoses (e.g. Subjective complaints of memory deficit, most frequently in the following area: No objective evidence of memory deficit on clinical interview. Applications are available at the American Dental Association web site. 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%. It is rare occurrence in the U.S. E41 is used to report nutritional marasmus, a form of malnutrition characterized by consumption of . They are examples of findings that generally connote a poor prognosis. Other clinical variables not on this list may support a six-month or less life expectancy. The page could not be loaded. Non-disease specific baseline guidelines (both A and B should be met), Part III. While every effort has MACs are Medicare contractors that develop LCDs and process Medicare claims. 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. descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work Pulmonary Disease. 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 Palliative Performance Scale (PPS) is a modification of the Karnofsky Performance Scale intended for evaluating patients requiring palliative care. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be Neurologic disease (CVA, ALS, MS, Parkinsons), Refractory severe autoimmune disease (e.g. 708 0 obj <>stream All rights reserved. While these characteristics are assessed along a continuum, rather than as discrete variables, they are useful in formulating and documenting a diagnosis of malnutrition. 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. The two main criteria are the American Society for Parenteral and Enteral Nutrition (ASPEN) and the Global Leadership Initiative on Malnutrition (GLIM). Instructions for enabling "JavaScript" can be found here. Stroke. Estimated glomerular filtration rate (GFR) <10 ml/min. 0000037443 00000 n Extent and determinants of error in doctors prognoses in terminally ill patients: prospective cohort study. 0000008630 00000 n West J Med. Accessed 01/16/2008.Schag CC, Heinrich RL, Ganz, PA. Karnofsky performance status revisited: Reliability, validity, and guidelines. Almost always recall their own name. + Life-threatening complications as demonstrated by one of the following characteristics occurring within the 12 months preceding initial hospice certification: Recurrent aspiration pneumonia (with or without tube feedings); Upper urinary tract infection, e.g., pyelonephritis; Recurrent fever after antibiotic therapy; Stage seven or beyond according to the Functional Assessment Staging Scale. ; Obstructive hydrocephalus in patient who declines, or is not a candidate for, ventriculoperitoneal shunt. ): 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. Some patients decline rapidly and die quickly; others progress more slowly. Factors from 3 will add supporting documentation. 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. Include supporting events such as a change in the level of activities of daily living, recent hospitalizations, and the known date of death (if you are billing for a period of time prior to the billing period in which death occurred. ): Increasing pCO2 or decreasing pO2 or decreasing SaO2; Increasing calcium, creatinine or liver function studies; Increasing tumor markers (e.g. CDT is a trademark of the ADA. CPT is a trademark of the American Medical Association (AMA). %PDF-1.4 % It places patients in one of four categories, based on how much they are limited during physical activity: patients with no limitation of activities; they suffer no symptoms from ordinary activities. such information, product, or processes will not infringe on privately owned rights. Applicable FARS\DFARS Restrictions Apply to Government Use. A hospice needs to be certain that the physician's clinical judgment can be supported by clinical information and other documentation that provide a basis for the certification of 6 months or less if the illness runs its normal course.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. The patient is not seeking dialysis or renal transplant, or is discontinuing dialysis. 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. The AMA assumes no liability for data contained or not contained herein. All verbal abilities are lost. Able to carry on normal activity and to work; no special care needed. Many patients exhibit symptoms of both disease states. Evaluating cancer patients for rehabilitation potential. "JavaScript" disabled. 646 0 obj <> endobj Please note that codes (CPT/HCPCS and ICD-10) have moved from LCDs to Billing & Coding Articles. Laboratory tests in protein-calorie malnutrition. Physiologic impairment of functional status as demonstrated by: Karnofsky Performance Status (KPS) or Palliative Performance Score (PPS) < 70%. Marasmus, or PEM without edema, is . 0000010879 00000 n Systemic hypertension; coronary artery disease; diabetes mellitus; history of cardiotoxic drug therapy or alcohol abuse; personal history of rheumatic fever; family history of cardiomyopathy. 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. Patients who have current or prior symptoms of HF associated with underlying structural heart disease. Revision Explanation:Converted policy into new policy template that no longer includes coding section based on CR 10901. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely. Severely disabled; hospital admission is indicated although death not imminent. documentation. Hence, it was concluded that albumin cannot be reliably used as a marker for diagnosing protein-calorie malnutrition . Neither the United States Government nor its employees represent that use of At least two of the six characteristics are needed for the diagnosis of malnutrition. A beneficiary may match a guideline, but by virtue of that individual having lived for a significantly prolonged period thereafter, he/she has shown that guideline to be inadequate to predict the appropriate terminal prognosis.ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult: Executive Summary A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1995 Guidelines for the Evaluation and Management of Heart Failure)Stages of Heart Failure (HF)Stage APatients at high risk of developing HF because of the presence of conditions that are strongly associated with the development of HF. 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. 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. The lower the Karnofsky score, the worse the survival for most serious illnesses.KARNOFSKY PERFORMANCE STATUS SCALE DEFINITIONS RATING (%) CRITERIA. 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. Stage 5 (Early Dementia) Moderately severe cognitive decline. 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. Goal: 90%. These should be documented in the clinical record. In such cases, it is important for providers to meticulously document the factors which specify the individuals terminal prognosis.There are also patients who match a guideline at the start of hospice care, and who continue to do so for a prolonged period, e.g., greater than six months. on this web site. CMS and its products and services are 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. If your session expires, you will lose all items in your basket and any active searches. 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. 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. Patients with dementia should show all the following characteristics: Stage seven or beyond according to the Functional Assessment Staging Scale; Urinary and fecal incontinence, intermittent or constant; No consistently meaningful verbal communication: stereotypical phrases only or the ability to speak is limited to six or fewer intelligible words. Protein and calorie deficiencies alter insulin, growth hormone and cortisol levels, curtail hepatic function, and deplete mineral stores. Instructions for enabling "JavaScript" can be found here. 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. 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). "JavaScript" disabled. 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.