You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement. This bibliography presents those sources that were obtained during the development of this policy. 0000040858 00000 n 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; 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. Your MCD session is currently set to expire in 5 minutes due to inactivity. It was adopted by the Center for Medicare and Medicaid Services (CMS) as part of the Hospital Inpatient Quality Reporting Program and will go into effect in 2024. CDT is a trademark of the ADA. presented in the material do not necessarily represent the views of the AHA. End User Point and Click Amendment: Alzheimer's disease and other progressive dementias are life-altering and eventually fatal conditions for which curative therapy is not available. The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. ALS tends to progress in a linear fashion over time. 2001;134:1097-1143.McCluskey L, Houseman G. Medicare hospice referral criteria for patients with amyotrophic lateral sclerosis: a need for improvement. The views and/or positions You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. 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. (1 and 2 should be present, factors from 3 will lend supporting documentation. Studies enrolling individuals with planned admissions (e.g. Severity of malnutrition is based on phenotypic criteria only and requires one phenotypic criterion that meets the threshold of . Cachexia should have been listed as i. and not beside Albumin with ii, this has been corected. 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. Requires considerable assistance and frequent medical care. Examination by a neurologist within three months of assessment for hospice is advised, both to confirm the diagnosis and to assist with prognosis. Stage 1No cognitive decline. 1973 May 12;1(7811):1041-2. 1991;155:384-387.Reisberg B. ElderCare online. In end-state ALS, two factors are critical in determining prognosis: ability to breathe, and to a lesser extent ability to swallow. Applications are available at the AMA Web site, http://www.ama-assn.org/go/cpt. K. Ogle, B. Mavis, G. Wyatt. Recertification for hospice care requires the same clinical standards be met as for initial certification, but they need not be reiterated. patients with slight, mild limitation of activity; they are comfortable with rest or with mild exertion. 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. 0000022017 00000 n 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. These guidelines are to be used in conjunction with the Non-disease specific baseline guidelines described in Part II. Many patients exhibit symptoms of both disease states. Ogle K, Mavis B, Wang T. Hospice and primary care physicians: attitudes, knowledge, and barriers. such information, product, or processes will not infringe on privately owned rights. Severely disabled; hospital admission is indicated although death not imminent. Co-morbidities. (1 and 2 should be present. 1994;73:2087-2098.Hurst JW, Morris DC, Alexander RW. 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. (Should fulfill 1, 2, or 3). 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 All billing and coding information was previously moved to the related Billing and Coding Article, A52830. Patients 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. End Users do not act for or on behalf of the CMS. 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; 0000009983 00000 n 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). Patient should demonstrate both rapid progression of ALS and critical nutritional impairment. + Current Dental Terminology © 2022 American Dental Association. If your session expires, you will lose all items in your basket and any active searches. Revision Explanation: Annual review, no changes made. Coverage Indications, Limitations, and/or Medical Necessity. Annals of Internal Medicine. Applicable FARS\DFARS Restrictions Apply to Government Use. There has been no change in coverage with this LCD revision. Also, you can decide how often you want to get updates. small cell lung cancer, brain cancer and pancreatic cancer) may be hospice eligible without fulfilling the other criteria in this section. (Documentation of serial decrease of FEV1>40 ml/year is objective evidence for disease progression, but is not necessary to obtain. A: Determining when to query for a malnutrition diagnosis can be very tricky. Progressive malnutrition, muscle wasting with dec. strength, ongoing alcoholism (>80 gm . ), 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.) Progression of disease differs markedly from patient to patient. Muscle wasting with reduced strength and endurance; Continued active alcoholism (>80 gm ethanol/day); Hepatitis C refractory to interferon treatment. Unintentional progressive weight loss of greater than 10% of body weight over the preceding six months. 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. Weight loss 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. CEA, PSA); Progressively decreasing or increasing serum sodium or increasing serum potassium. Manifestations in more than one of the following areas: Objective evidence of memory deficit obtained only with an intensive interview. Mild to moderate anxiety accompanies symptoms. 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. Frequently there is no speech at all - only grunting. Factors from 5 will lend supporting documentation.). CPT codes, descriptions and other data only are copyright 2022 American Medical Association. 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. CMS and its products and services are not endorsed by the AHA or any of its affiliates. Any questions pertaining to the license or use of the CPT should be addressed to the AMA. copied without the express written consent of the AHA. Baseline data may be established on admission to hospice or by using existing information from records. special, incidental, or consequential damages arising out of the use of such information, product, or process. Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, 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. <]/Prev 527120/XRefStm 1970>> ): Increasing pCO2 or decreasing pO2 or decreasing SaO2; Increasing calcium, creatinine or liver function studies; Increasing tumor markers (e.g. Factors from 5 will lend supporting documentation. 0000008839 00000 n %%EOF Although guidelines applicable to certain disease categories are included, this policy is applicable to all hospice patients. At least two of the six characteristics are needed for the diagnosis of malnutrition. such information, product, or processes will not infringe on privately owned rights. Federal government websites often end in .gov or .mil. 0000060832 00000 n Nutritional supplementation is one of the most important interventions in patients with failure to thrive. 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. 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 FAST scale has 16 stages and sub-stages: Personal awareness of some functional decline. To submit a comment or question to CMS, please use the Feedback/Ask a Question link available at the bottom 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. Patients with congestive heart failure or angina should meet the criteria for the New York Heart Association (NYHA) Class IV. Will require some assistance with activities of daily living, e.g., may become incontinent, will require travel assistance but occasionally will display ability to familiar locations. CPT codes, descriptions and other data only are copyright 2022 American Medical Association. AJ Hospice & Palliative Care, 2003; 20; 41-51. - Social Security Act, Sections 1102, 1812 (a)(4) and (d); 1813 (a) (4); 1814 (a)(7) and (I); 1862 (a)(1), (6), and (9); 1861 (dd), 1871- 42 CFR Part 418- CMS Publication 100-02, Medicare Benefit Policy, Chapter 9.- CMS Publication 100-04, Medicare Claims Processing, Chapter 30. While not necessarily a contraindication to Hospice Care, the decision to institute either artificial ventilation or artificial feeding will significantly alter six-month prognosis. Clin Cardiol. 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. and the State Children's Health Insurance Programs, contracts with certain organizations to assist in the administration of the Measuring quality of life in stroke. 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. Thus, the overall rate of decline in each patient is fairly constant and predictable, unlike many other non-cancer diseases. Thus the overall rate of decline in each patient is fairly constant and predictable, unlike many other non-cancer diseases. No memory deficit evident on clinical interviews. Able to carry on normal activity; minor signs or symptoms of disease. 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. Please note that if you choose to continue without enabling "JavaScript" certain functionalities on this website may not be available. The criteria refer to patients with various forms of advanced pulmonary disease who eventually follow a final common pathway for end stage pulmonary disease. 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. 0000005794 00000 n LCDs are specific to an item or service (procedure) and they define the specific diagnosis (illness or injury) for which the item or service is covered. on this web site. 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. 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. Factors from 3 will add supporting documentation. By the time patients become end-stage, muscle denervation has become widespread, affecting all areas of the body, and initial predominance patterns do not persist. If a patient improves 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. They may be incorporated by specific reference as part (or all) of the indication for recertification. Before an LCD becomes final, the MAC publishes Proposed LCDs, which include a public comment period. ), Progression of end stage pulmonary disease, as evidenced by increasing visits to the emergency department or hospitalizations for pulmonary infections and/or respiratory failure or increasing physician home visits prior to initial certification. Serum creatinine > 8.0 mg/dl (>6.0 mg/dl for diabetics). Hospice and primary care physicians: attitudes, knowledge, and barriers. This can be used to compare effectiveness of different therapies and to assess the prognosis in individual patients. Note, however, paragraph 3 of 'General Indications' under "Indications and Limitations of Coverage and/or Medical Necessity" regarding patients who improve or stabilize.Documentation should paint a picture for the reviewer to clearly see why the patient is appropriate for hospice care and the level of care provided, i.e., routine home, continuous home, inpatient respite, or general inpatient. 0000032947 00000 n Applications are available at the American Dental Association web site. The AMA assumes no liability for data contained or not contained herein. THE INFORMATION, PRODUCT, OR PROCESSES DISCLOSED HEREIN. The A.S.P.E.N. Documentation of 3, 4, and 5, will lend supporting documentation.). recipient email address(es) you enter. Please note that codes (CPT/HCPCS and ICD-10) have moved from LCDs to Billing & Coding Articles. Lose basic psychomotor skills, e.g., ability to walk, sitting and head control. and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only Neither the United States Government nor its employees represent that use of preparation of this material, or the analysis of information provided in the material. required field. 646 0 obj <> endobj FVC < 40% predicted (seated or supine) and 2 or more of the following symptoms and/or signs: If unable to perform the FVC test patients meet this criterion if they manifest 3 or more of the above symptoms/signs. These situations are obvious. Examination by a neurologist within three months of assessment for hospice is advised, both to confirm the diagnosis and to assist with prognosis. ), Hypoxemia at rest on room air, as evidenced by pO2 less than or equal to 55 mmHg, or oxygen saturation less than or equal to 88%, determined either by arterial blood gases or oxygen saturation monitors, (these values may be obtained from recent hospital records) OR hypercapnia, as evidenced by pCO2 greater than or equal to 50 mmHg.
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