Factors from 5 will lend supporting documentation. At the time of initial certification or recertification for hospice, the patient is or has been already optimally treated for heart disease, or are patients who are either not candidates for surgical procedures or who decline those procedures. The criteria refer to patients with various forms of advanced pulmonary disease who eventually follow a final common pathway for end stage pulmonary disease. 0000037443 00000 n LCDs outline how the contractor will review claims to ensure that the services provided meet Medicare coverage requirements. To submit a comment or question to CMS, please use the Feedback/Ask a Question link available at the bottom ): 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. special, incidental, or consequential damages arising out of the use of such information, product, or process. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials. Revision Explanation: Annual review no changes made. ), 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. patient declines further disease directed therapyNote: Certain cancers with poor prognoses (e.g. Before an LCD becomes final, the MAC publishes Proposed LCDs, which include a public comment period. or to place. Patients 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. Nausea/vomiting poorly responsive to treatment. 0000037955 00000 n Lab testing is not required to establish hospice eligibility. 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. 0000008075 00000 n There are multiple ways to create a PDF of a document that you are currently viewing. > The Tracking Sheet modal can be closed and re-opened when viewing a Proposed LCD. 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. See Part III for disease specific guidelines to be used with these baseline guidelines. descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work 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 CMS.gov Web site currently does not fully support browsers with Patients 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: Patients at high risk of developing HF because of the presence of conditions that are strongly associated with the development of HF. The patient is not seeking dialysis or renal transplant, or is discontinuing dialysis. Organizations who contract with CMS acknowledge that they may have a commercial CDT license with the ADA, and that use of CDT codes as permitted herein for the administration of CMS programs does not extend to any other programs or services the organization may administer and royalties dues for the use of the CDT codes are governed by their commercial license. Proposed LCD document IDs begin with the letters "DL" (e.g., DL12345). CPT is a trademark of the American Medical Association (AMA). endstream endobj 659 0 obj <>stream The page could not be loaded. The Palliative Performance Scale (PPS) is a modification of the Karnofsky Performance Scale intended for evaluating patients requiring palliative care. 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. Right heart failure (RHF) secondary to pulmonary disease (Cor pulmonale) (e.g., not secondary to left heart disease or valvulopathy). Patient declines further disease directed therapy. of every MCD page. 844-4CHILDRENS (844-424-4537) 844-424-4537; Patient Login (MyChart . 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. It was developed in British Columbia, Canada. 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). 0000011336 00000 n HUjI}iuU!v` "Y]I!T 3:NU^#={6: K]Sdl*B!XA-m2{gcm8n W)' fvtkW~e,y&2%!98kzb . Applications are available at the American Dental Association web site. As used herein, "you" and "your" refer to you and any organization on behalf of which you are acting. ), 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 criteria refer to patients with various forms of advanced pulmonary disease who eventually follow a final common pathway for end stage pulmonary disease. CPT codes, descriptions and other data only are copyright 2022 American Medical Association. E40 refers to Kwashiorkor is severe malnutrition with nutritional edema and dyspigmentation of skin and hair. 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. 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. They invariably know their own names and generally know their spouse's and children's names. Although guidelines applicable to certain disease categories are included, this LCD is applicable to all hospice patients. Use is limited to use in Medicare, Medicaid or other programs administered by the Centers for Medicare and Medicaid Services (CMS). Progression of disease as documented by worsening clinical status, symptoms, signs and laboratory results. The AMA assumes no liability for data contained or not contained herein. AHA copyrighted materials including the UB‐04 codes and But specific entries can also call for an answer, such as an opinion by one team member or recovery of ADLS when they were part of the basis for the initial declaration of eligibility. Some patients may not meet these guidelines, yet still have a life expectancy of 6 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. For this reason, the history of the rate of progression in individual patients is important to obtain to predict prognosis. 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. (Should fulfill 1, 2, or 3). A patient will be considered to have a life expectancy of six months or less if he/she meets the non-disease specific. Stage2 (Forgetfulness)Very mild cognitive decline. )ndgM`.K3{daYpz:=~F~c~Cm& m& m& m& m#=#)XOz 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. If any physical activity is undertaken, discomfort is increased.) Organizations who contract with CMS acknowledge that they may have a commercial CDT license with the ADA, and that use of CDT codes as permitted herein for the administration of CMS programs does not extend to any other programs or services the organization may administer and royalties dues for the use of the CDT codes are governed by their commercial license. (1 and 2 should be present. Goal: 90%. 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. Creatinine clearance < 10 cc/min (<15 cc/min. No objective deficits in employment or social situations. If your session expires, you will lose all items in your basket and any active searches. Lupus or Rheumatoid Arthritis). Unable to work; able to live at home and care for most personal needs; varying amount of assistance needed. 0000037874 00000 n authorized with an express license from the American Hospital Association. The Centers for Medicare & Medicaid Services (CMS), the federal agency responsible for administration of the Medicare, Medicaid 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 06/30/2022, AMA CPT / ADA CDT / AHA NUBC Copyright Statement, Coverage Indications, Limitations, and/or Medical Necessity, Analysis of Evidence (Rationale for Determination), LCD - Hospice Determining Terminal Status (L34538). CMS and its products and services are Therefore, multiple clinical parameters are required to judge the progression of ALS. Earliest clear-cut deficits. 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. 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. The 2023 edition of ICD-10-CM E46 became effective on October 1, 2022. While not necessarily a contraindication to Hospice care, the decision to institute either artificial ventilation or artificial feeding may significantly alter six month prognosis. R2Revision Effective: N/ARevision Explanation: Annual review no changes made. 0000040523 00000 n Protein and calorie deficiencies alter insulin, growth hormone and cortisol levels, curtail hepatic function, and deplete mineral stores. (1 and 2 should be present. GENERAL INDICATIONS:Medicare 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. 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; Journal of Palliative Medicine. Patient can no longer survive without some assistance. 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. As each patient is unique, there are patients for whom a particular guideline does not match. You can use the Contents side panel to help navigate the various sections. Left ventricular hypertrophy or fibrosis; left ventricular dilatation or hypocontractility; asymptomatic valvular heart disease; previous myocardial infarction. ), 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. Appropriate concern regarding symptoms. MACs are Medicare contractors that develop LCDs and process Medicare claims. (Class IV patients with heart disease have an inability to carry on any physical activity. Focusing on Protein-Calorie Malnutrition Protein-Calorie Malnutrition (PCM) The prevalence of protein-calorie malnutrition varies depending on the clinical setting. ): 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. 0000014780 00000 n 0000022017 00000 n documentation. 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. 2002;5:73-84.Hollen PJ, Gralla RJ, Dris MG, et al. 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. 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. Critically impaired breathing capacity as demonstrated by all the following characteristics occurring within the 12 months preceding initial hospice certification: Vital capacity (VC) less than 30% of normal (if available); Patient declines mechanical ventilation; external ventilation used for comfort measures only. 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.