. Another option is to use the Download button at the top right of the document view pages (for certain document types). H\0E Lose basic psychomotor skills, e.g., ability to walk, sitting and head control. Right heart failure (RHF) secondary to pulmonary disease (Cor pulmonale) (e.g., not secondary to left heart disease or valvulopathy). 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. There has been no change in coverage with this LCD revision. t'h0&@,41%;j4aJEG>wJ4RA0^c 1993:109.Friedman B, Harwood S. Barriers and enablers to hospice referrals: an expert overview. ), 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.) Pulmonary Disease. Recurrent or intractable serious infections such as pneumonia, sepsis or pyelonephritis; Weight loss of at least 10% body weight in the prior six months, not due to reversible causes such as depression or use of diuretics; Decreasing anthropomorphic measurements (mid-arm circumference, abdominal girth), not due to reversible causes such as depression or use of diuretics; Observation of ill-fitting clothes, decrease in skin turgor, increasing skin folds or other observation of weight loss in a patient without documented weight; Dysphagia leading to recurrent aspiration and/or inadequate oral intake documented by decreasing food portion consumption. 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. Federal government websites often end in .gov or .mil. Stage 4 (Late Confusional)Moderate cognitive decline. 0000001970 00000 n 0000005335 00000 n Retain some knowledge of their past lives but this is very sketchy. 0000001587 00000 n To capture use of hypocaloric PN dosing. Similarly, . Patients will be considered to be in the terminal stage of dementia (life expectancy of six months or less) if they meet the following criteria. (Should fulfill 1, 2, or 3). presented in the material do not necessarily represent the views of the AHA. All rights reserved. Please do not use this feature to contact CMS. Sign up to get the latest information about your choice of CMS topics in your inbox. Although ALS usually presents in a localized anatomical area, the location of initial presentation does not correlate with survival time. Current Dental Terminology © 2022 American Dental Association. All rights reserved. An asterisk (*) indicates a routine or continuous home or inpatient, respite, or general. However, no single variable deteriorates at a uniform rate in all patients. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or (Optimally treated means that patients who are not on vasodilators have a medical reason for refusing these drugs, e.g., hypotension or renal disease.). This is the American ICD-10-CM version of E43 - other international versions of ICD-10 E43 may differ. 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. 0 End Users do not act for or on behalf of the CMS. Although guidelines applicable to certain disease categories are included, this policy is applicable to all hospice patients. They are listed in order of their likelihood to predict poor survival, the most predictive first and the least predictive last. Earliest clear-cut deficits. 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. 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. Patient can no longer survive without some assistance. 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). In addition, an administrative law judge may not review an NCD. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. Clinical variables with general applicability without regard to diagnosis, as well as clinical variables applicable to a limited number of specific diagnoses, are provided. Part I. 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. J Palliative Medicine. The views and/or positions presented in the material do not necessarily represent the views of the AHA. (1 and 2 should be present. Also, you can decide how often you want to get updates. Reproduced with permission. See 1869(f)(1)(A)(i) of the Social Security Act. 0000025584 00000 n 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. 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. E. Lamont, N. Christakis. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be The guidelines for LCD development are provided in Chapter 13 of the Medicare Program Integrity Manual. 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. Subject to the terms and conditions contained in this Agreement, you, your employees and agents are authorized to use CDT only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. 646 0 obj <> endobj 0000037804 00000 n Progressive loss of abilities to walk, sit up, smile, and hold head up. 0000016419 00000 n (Documentation of serial decrease of FEV1>40 ml/year is objective evidence for disease progression, but is not necessary to obtain. The Tracking Sheet provides key details about the Proposed LCD, including a summary of the issue, who requested the new/updated policy, links to key documents, important process-related dates, who to contact with questions about the policy, and the history of previous policy considerations. B. 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. The CMS.gov Web site currently does not fully support browsers with ): 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. 1993;24:320- 327.Doyle D, Hanks G, Cherny N and Calman K. Oxford textbook of palliative medicine. trailer without the written consent of the AHA. 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. The criteria refer to patients with various forms of advanced pulmonary disease who eventually follow a final common pathway for end stage pulmonary disease. and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only In no event shall CMS be liable for direct, indirect, Speech ability declines to about a half-dozen intelligible words. 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. 0000002310 00000 n Revision Explanation: Annual review no changes made. authorized with an express license from the American Hospital Association. CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. Disabled; requires special care and assistance. To submit a comment or question to CMS, please use the Feedback/Ask a Question link available at the bottom Right heart failure (RHF) secondary to pulmonary disease (Cor pulmonale) (e.g., not secondary to left heart disease or valvulopathy). Neither the United States Government nor its employees represent that use of Please note that codes (CPT/HCPCS and ICD-10) have moved from LCDs to Billing & Coding Articles. CPT codes, descriptions and other data only are copyright 2022 American Medical Association. Diurnal rhythm frequently disturbed. Reproduced with permission. Skip to main content Skip to navigation Skip to navigation. The page could not be loaded. Note that two of the disease specific guidelines (HIV Disease, Stroke and Coma) establish a lower qualifying KPS or PPS. 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. Rapid progression of ALS as demonstrated by all the following characteristics occurring within the 12 months preceding initial hospice certification: Progression from independent ambulation to wheelchair to bed bound status; Progression from normal to barely intelligible or unintelligible speech; Progression from independence in most or all activities of daily living (ADLs) to needing major assistance by caretaker in all ADLs. 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. 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. The criteria refer to patients with various forms of advanced pulmonary disease who eventually follow a final common pathway for end stage pulmonary disease. ), Chronic Kidney Disease (1 and either 2, 3 or 4 should be present. In end-state ALS, two factors are critical in determining prognosis: ability to breathe, and to a lesser extent ability to swallow. )Documentation should support the level of care being provided to the patient during the time period under review, i.e. 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. OR Hypercapnia, as evidenced by pCO2 50 mmHg. Documentation of 3, 4, and 5, will lend supporting documentation. Although ALS usually presents in a localized anatomical area, the location of initial presentation does not correlate with survival time. )ndgM`.K3{daYpz:=~F~c~Cm& m& m& m& m#=#)XOz You can use the Contents side panel to help navigate the various sections. The former can be managed by artificial ventilation, and the latter by gastrostomy or other artificial feeding, unless the patient has recurrent aspiration pneumonia. For this reason, the history of the rate of progression in individual patients is important to obtain to predict prognosis. 0000017107 00000 n 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. Recommendation: Target blood glucose range of 140 - 180 mg\dL for the general ICU population. 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. You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement. patients with marked limitation of activity; they are comfortable only at rest. In end-state ALS, two factors are critical in determining prognosis: ability to breathe, and to a lesser extent ability to swallow. HMn1>.`Ax! The use of the New York heart association's classification of cardiovascular disease as part of the patient's complete problem list. Non-disease specific baseline guidelines (both A and B should be met), Part III. Although guidelines applicable to certain disease categories are included, this LCD is applicable to all hospice patients. 0000007316 00000 n (1 and 2 should be present; factors from 3 will add supporting documentation): Patients 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. special, incidental, or consequential damages arising out of the use of such information, product, or process. Disease with distant metastases at presentation ORB. Protein-Energy Malnutrition / diagnosis Serum Albumin / analysis Substances Amino Acids . 0000002894 00000 n 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%. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or 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. CMS and its products and services are CDT is a trademark of the ADA. They would use ICD-10-CM code E42 to report severe protein-calorie malnutrition with signs of both kwashiorkor and marasmus. Your MCD session is currently set to expire in 5 minutes due to inactivity. 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. Current Dental Terminology © 2022 American Dental Association. Will be largely unaware of all recent events and experiences in their lives. 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. Muscle wasting with reduced strength and endurance; Continued active alcoholism (> 80 gm ethanol/day); Hepatitis C refractory to interferon treatment. While these characteristics are assessed along a continuum, rather than as discrete variables, they are useful in formulating and documenting a diagnosis of malnutrition. The Social Security Act, Sections 1869(f)(2)(B) and 1862(l)(5)(D) define LCDs and provide information on the process. Patients with advanced structural heart disease and marked symptoms of HF at rest despite maximal medical therapy and who require specialized interventions. Progression of disease differs markedly from patient to patient. No objective deficits in employment or social situations. and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only Factors from 5 will lend supporting documentation. 5 $q`$Hx OmR1ShJ6yehl~"YQiy8{ f P?9G5RW\t 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. 0000039400 00000 n N. Christakis, E. Lamont. It was developed in British Columbia, Canada. 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 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. 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 AHA copyrighted materials including the UB‐04 codes and 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. This Agreement will terminate upon notice if you violate its terms. (1 and either 2, 3 or 4 should be present. An official website of the United States government. 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. Use is limited to use in Medicare, Medicaid or other programs administered by the Centers for Medicare and Medicaid Services (CMS). 0000040550 00000 n 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. Note: Certain cancers with poor prognoses (e.g. Experiences urinary and fecal incontinence. Neurologic disease (CVA, ALS, MS, Parkinsons), Refractory severe autoimmune disease (e.g. 26 Because the goal of dietary supplements is to provide adequate energy and protein. not endorsed by the AHA or any of its affiliates. While most healthcare facilities still follow the previous ASPEN criteria, in 2018, ASPEN joined with the . The Centers for Medicare & Medicaid Services (CMS), the federal agency responsible for administration of the Medicare, Medicaid Inability to maintain hydration and caloric intake with 1 of the following: weight loss >10% in the last 6 months or >7. . the medical record and for coders to be aware of malnutrition as a potential diagnosis (ICD-10-CM codes E44.0, E44.1 and E46). Studies enrolling individuals with planned admissions (e.g. Secondary Criteria Notes . 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. Patient should demonstrate both rapid progression of ALS and life-threatening complications. The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. 0000004098 00000 n The views and/or positions Protein Calorie Malnutrition Severe Protein Calorie Malnutrition Moderate Protein Calorie Malnutrition Severe Protein Calorie Malnutrition Energy Intake <75% of EEE >7 days 50 % of EEE >5 days <75% of EEE 1 month <75% of EEE 1 month <75% of EEE 3 months 50% of EEE 1 month Weight Loss Measurement of quality of life in patients with lung cancer in multicenter trials of new therapies. 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. These situations are obvious. Federal government websites often end in .gov or .mil. The score can help determine which patients can be managed in the home and which should be admitted to a hospice unit. The AMA does not directly or indirectly practice medicine or dispense medical services. Cancer. required field. 0000015606 00000 n Ogle K, Mavis B, Wang T. Hospice and primary care physicians: attitudes, knowledge, and barriers. LCD document IDs begin with the letter "L" (e.g., L12345). authorized with an express license from the American Hospital Association. 0000037443 00000 n Moribund; fatal processes progressing rapidly. 2003;20: 41-51.Ogle K, Mavis B, Wang T. Physicians and hospice care: attitudes, knowledge and referrals. C. Heart Disease. CMS believes that the Internet is an effective method to share LCDs that Medicare contractors develop. 0000038836 00000 n 0000012375 00000 n 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. At least two of the six characteristics are needed for the diagnosis of malnutrition. Severely disabled; hospital admission is indicated although death not imminent. 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. Annals of Internal Medicine 2001; 134; 1097-1143. As used herein, "you" and "your" refer to you and any organization on behalf of which you are acting. 0000015750 00000 n such information, product, or processes will not infringe on privately owned rights. 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. The AMA assumes no liability for data contained or not contained herein. 0000038995 00000 n 2002;5:73-84.Hollen PJ, Gralla RJ, Dris MG, et al. 0000032947 00000 n As used herein, "you" and "your" refer to you and any organization on behalf of which you are acting. "JavaScript" disabled. Unintentional progressive weight loss of greater than 10% of body weight over the preceding six months. <]/Prev 527120/XRefStm 1970>> The 2023 edition of ICD-10-CM E46 became effective on October 1, 2022. Revision Explanation:Converted policy into new policy template that no longer includes coding section based on CR 10901. Patients will be considered to be in the terminal stages of stroke or coma (life expectancy of 6 months or less) if they meet the following criteria: Stroke: KPS or Palliative Performance Scale of 40% or less. These guidelines are to be used in conjunction with the Non-disease specific baseline guidelines described in Part II.

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