0000011336 00000 n Unspecified severe protein-calorie malnutrition. 0000001587 00000 n Factors from 3 will add supporting documentation. The Centers for Medicare & Medicaid Services (CMS), the federal agency responsible for administration of the Medicare, Medicaid Medicare program. Medicare contractors are required to develop and disseminate Local Coverage Determinations (LCDs). (1 and 2 should be present. Patients with congestive heart failure or angina should meet the criteria for the New York Heart Association (NYHA) Class IV. It is rare occurrence in the U.S. E41 is used to report nutritional marasmus, a form of malnutrition characterized by consumption of . A patient will be considered to have a life expectancy of six months or less if he/she meets the non-disease specific. such information, product, or processes will not infringe on privately owned rights. Inability to maintain sufficient fluid and calorie intake with 10% weight loss during the previous six months or serum albumin <2.5 gm/dl . The scope of this license is determined by the AMA, the copyright holder. Stage 4 (Late Confusional)Moderate cognitive decline. OR Hypercapnia, as evidenced by pCO2 50 mmHg. Please enable "JavaScript" and revisit this page or proceed with browsing CMS.gov with Factors from 5 will lend supporting documentation.). If you are experiencing any technical issues related to the search, selecting the 'OK' button to reset the search data should resolve your issues. Factors from 5 will lend supporting documentation. > CMS believes that the Internet is an effective method to share LCDs that Medicare contractors develop. 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; (Should fulfill 1, 2, or 3). CPT codes, descriptions and other data only are copyright 2022 American Medical Association. 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). The guidelines for LCD development are provided in Chapter 13 of the Medicare Program Integrity Manual. 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. There is no regulation precluding patients on dialysis from electing Hospice care. West J Med. recipient email address(es) you enter. To capture use of hypocaloric PN dosing. While every effort has As used herein, "you" and "your" refer to you and any organization on behalf of which you are acting. Requires considerable assistance and frequent medical care. The Palliative Performance Scale (PPS) is a modification of the Karnofsky Performance Scale intended for evaluating patients requiring palliative care. 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. They are listed in order of their likelihood to predict poor survival, the most predictive first and the least predictive last. End User License Agreement: The views and/or positions 0000009368 00000 n All Rights Reserved. Please do not use this feature to contact CMS. 0000014780 00000 n AbstractMedicare 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. Measuring quality of life in stroke. Amyotrophic Lateral Sclerosis General Considerations: Criteria:Patients will be considered to be in the terminal stage of ALS (life expectancy of six months or less) if they meet the following criteria. Our audit covered $3.4 billion in Medicare payments for 224,175 claims with a discharge date in fiscal year (FY) 2016 or 2017 that contained a severe malnutrition diagnosis code and for which removing the diagnosis code changed the diagnosis-related group (DRG). 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. The score can help determine which patients can be managed in the home and which should be admitted to a hospice unit. 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. Surface area of involvement of hemorrhage 30% of cerebrum; Obstructive hydrocephalus in patient who declines, or is not a candidate for, ventriculoperitoneal shunt. They may be incorporated by specific reference as part (or all) of the indication for recertification. They would use ICD-10-CM code E42 to report severe protein-calorie malnutrition with signs of both kwashiorkor and marasmus. Muscle wasting with reduced strength and endurance; Continued active alcoholism (>80 gm ethanol/day); Hepatitis C refractory to interferon treatment. MACs are Medicare contractors that develop LCDs and process Medicare claims. preparation of this material, or the analysis of information provided in the material. AJ Hospice & Palliative Care. Baker D, Chin M, Cinquigrani M, et al. 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. Earliest clear-cut deficits. 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. E46 - Unspecified protein calorie malnutrition E64 - Sequelae of protein calorie malnutrition. This page displays your requested Local Coverage Determination (LCD). Copyright © 2022, the American Hospital Association, Chicago, Illinois. ), 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. 4 Methodologies to Determine Hospice Eligibility Meets Local Coverage Determinations (LCD) Meets most LCD guidelines and documented decline Meets most LCD guidelines and additional co-morbidities Physician's clinical judgment Guidelines & Indicators General Guidelines Non-specific Disease Guidelines International Classification of Functioning Goal: 90%. ), 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. Progressive loss of abilities to walk, sit up, smile, and hold head up. Coverage for these patients may be approved if documentation otherwise supporting a less than six-month life expectancy is provided. Proposed LCD document IDs begin with the letters "DL" (e.g., DL12345). CEA, PSA); Progressively decreasing or increasing serum sodium or increasing serum potassium. 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. Percentage of patients receiving PN in the ICU who receive 80% of estimated energy requirements or 20 kcals/kg/day and a minimum of 1.2 g protein/kg/day. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. Measurement of quality of life in patients with lung cancer in multicenter trials of new therapies. copied without the express written consent of the AHA. 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. However, no single variable deteriorates at a uniform rate in all patients. The most severe malnutrition problems are associated with protein-calorie malnutrition (PCM), also known as protein-energy malnutrition or protein calorie undernutrition, which occurs in both chronic and acute forms. While every effort has . 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. THE INFORMATION, PRODUCT, OR PROCESSES DISCLOSED HEREIN. Before sharing sensitive information, make sure you're on a federal government site. Noticeable deficits in demanding job situations. At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. routine or continuous home or inpatient, respite, or general. 0000007316 00000 n 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. 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. 0000001970 00000 n The document is broken into multiple sections. Personality and emotional changes occur. Diurnal rhythm frequently disturbed. Frequently no deficit in the following areas: Inability to perform complex tasks. 646 63 They are examples of findings that generally connote a poor prognosis. 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. 0000037087 00000 n You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. It was developed in British Columbia, Canada. CPT is a trademark of the American Medical Association (AMA). 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. P rint Checklist: Documenting malnutrition (E41 and E43) This checklist is intended to provide healthcare providers with a reference for use when responding to medical documentation requests for services rendered and hospital admissions to treat malnutrition. Part III. 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%. 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. Laboratory tests in protein-calorie malnutrition. Protein-Energy Malnutrition / diagnosis Serum Albumin / analysis Substances Amino Acids . Requires assistance in complicated tasks such as handling finances, planning parties,etc. Progression to dependence on assistance with additional activities of daily living (see Part II, Section 2). Inability to maintain hydration and caloric intake with 1 of the following: weight loss >10% in the last 6 months or >7. . Clin Cardiol. required field. It was developed in British Columbia, Canada. 7500 Security Boulevard, Baltimore, MD 21244. Please note that codes (CPT/HCPCS and ICD-10) have moved from LCDs to Billing & Coding Articles. 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. Baseline data may be established on admission to hospice or by using existing information from records. ), 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. This bibliography presents those sources that were obtained during the development of this policy. ), (1 and either 2 or 3 should be present. Patients with dementia or Alzheimer's are eligible for hospice care when they show all of the following characteristics: 1. 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. 0000012920 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. Part II. 0000037443 00000 n 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. 0000029167 00000 n )ndgM`.K3{daYpz:=~F~c~Cm& m& m& m& m#=#)XOz While not necessarily a contraindication to Hospice Care, the decision to institute either artificial ventilation or artificial feeding will significantly alter six-month prognosis. Some patients may not meet these guidelines, yet still have a life expectancy of six months or less. Prognostic disclosure to patients with cancer near end of life. (1 and 2 should be present; factors from 3 will add supporting documentation. Skip to main content Skip to navigation Skip to navigation. Right heart failure (RHF) secondary to pulmonary disease (Cor pulmonale) (e.g., not secondary to left heart disease or valvulopathy). You acknowledge that the ADA holds all copyright, trademark and other rights in CDT. While it is true that there is not a strict six month limit on the Hospice benefit, the underlying precept is that the beneficiary must have a prognosis of six months or less, if the illness runs its normal course. endstream endobj 647 0 obj <>/Metadata 45 0 R/Pages 44 0 R/StructTreeRoot 47 0 R/Type/Catalog/ViewerPreferences<>>> endobj 648 0 obj <>/ExtGState<>/Font<>/ProcSet[/PDF/Text/ImageC]/Properties<>>>/XObject<>>>/Rotate 0/StructParents 0/TrimBox[0.0 0.0 612.0 792.0]/Type/Page>> endobj 649 0 obj <> endobj 650 0 obj <> endobj 651 0 obj [/ICCBased 686 0 R] endobj 652 0 obj [/ICCBased 687 0 R] endobj 653 0 obj <> endobj 654 0 obj <> endobj 655 0 obj <> endobj 656 0 obj <>stream R8Revision Effective: 05/06/2021Revision Explanation: Corrected typo in the associated information section under acute renal failure. For example, severe protein-calorie malnutrition cannot be considered a MCC for the principle diagnosis of "Failure to Thrive" because the two conditions are too similar. Patients who have current or prior symptoms of HF associated with underlying structural heart disease. 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. 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. Laboratory tests in protein-calorie malnutrition. Alzheimer's disease and other progressive dementias are life-altering and eventually fatal conditions for which curative therapy is not available. Documentation of 3, 4, and 5, will lend supporting documentation. Please do not use this feature to contact CMS. 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. CMS and its products and services are 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). malnutrition (263.0: Malnutrition of a Moderate Degree) and severe malnutrition (262: Other Severe Protein Calorie Malnutrition). Applicable Federal Acquisition Regulation Clauses (FARS)/Department of Defense Federal Acquisition Regulation supplement (DFARS) Restrictions Apply to Government Use. 0000015606 00000 n All rights reserved. %%EOF Certain cancers with poor prognoses (e.g., small cell lung cancer, brain cancer and pancreatic cancer) may be hospice eligible without fulfilling the other criteria in this section. 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. 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). If you would like to extend your session, you may select the Continue Button. These situations are obvious. 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. LCDs outline how the contractor will review claims to ensure that the services provided meet Medicare coverage requirements. Lab testing is not required to establish hospice eligibility. 0000037955 00000 n descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work Serum creatinine > 8.0 mg/dl (>6.0 mg/dl for diabetics). Although guidelines applicable to certain disease categories are included, this policy is applicable to all hospice patients. authorized with an express license from the American Hospital Association. Documentation of 3, 4, and 5, will lend supporting documentation. Critical nutritional impairment as demonstrated by all the following characteristics occurring within the 12 months preceding initial hospice certification: Oral intake of nutrients and fluids insufficient to sustain life; Absence of artificial feeding methods, sufficient to sustain life, but not for relieving hunger. 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. special, incidental, or consequential damages arising out of the use of such information, product, or process. The two main criteria are the American Society for Parenteral and Enteral Nutrition (ASPEN) and the Global Leadership Initiative on Malnutrition (GLIM). 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 is a third party beneficiary to this Agreement. (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. 0000060832 00000 n Note: Certain cancers with poor prognoses (e.g. 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. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or 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. The AMA does not directly or indirectly practice medicine or dispense medical services. Dyspnea with increasing respiratory rate; Nausea/vomiting poorly responsive to treatment; Pain requiring increasing doses of major analgesics more than briefly. The criteria refer to patients with various forms of advanced pulmonary disease who eventually follow a final common pathway for end stage pulmonary disease. 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. J Gerontol. 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. Although guidelines applicable to certain disease categories are included, this LCD is applicable to all hospice patients. 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. Applications are available at the American Dental Association web site. Also, you can decide how often you want to get updates. 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. However, the continuation of dialysis will significantly alter a patients prognosis, and thus potentially impact that individuals eligibility. Lab testing is not required to establish hospice eligibility. CPT codes, descriptions and other data only are copyright 2022 American Medical Association. No fee schedules, basic unit, relative values or related listings are included in CPT. and the State Children's Health Insurance Programs, contracts with certain organizations to assist in the administration of the 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. 0000003947 00000 n 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. 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. (1 and 2 should be present, factors from 3 will lend supporting documentation. Patient should demonstrate both rapid progression of ALS and critical nutritional impairment. There are multiple ways to create a PDF of a document that you are currently viewing. 0000004098 00000 n Before an LCD becomes final, the MAC publishes Proposed LCDs, which include a public comment period. 0000011855 00000 n Lupus or Rheumatoid Arthritis). Also, you can decide how often you want to get updates. Unable to ambulate without assistance. CMS and its products and services are 1984;2:187-193. Patients with dementia should show all the following characteristics: Patients should have had one of the following within the past 12 months: Note: This section is specific for Alzheimers Disease and related disorders, and is not appropriate for other types of dementia, such as multi-infarct dementia. The score can help determine which patients can be managed in the home and which should be admitted to a hospice unit. You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement. Part II. Documentation of 3, 4, and 5, will lend supporting documentation.). recommending their use. Hence, it was concluded that albumin cannot be reliably used as a marker for diagnosing protein-calorie malnutrition . Factors from 4 will lend supporting documentation. The AMA is a third party beneficiary to this Agreement. Progression of disease as documented by worsening clinical status, symptoms, signs and laboratory results. Such patients have no identified structural or functional abnormalities of the pericardium, myocardium, or cardiac valves and have never shown signs or symptoms of HF.Example:Systemic hypertension; coronary artery disease; diabetes mellitus; history of cardiotoxic drug therapy or alcohol abuse; personal history of rheumatic fever; family history of cardiomyopathy.Stage BPatients 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.Example:Left ventricular hypertrophy or fibrosis; left ventricular dilatation or hypocontractility; asymptomatic valvular heart disease; previous myocardial infarction.Stage CPatients who have current or prior symptoms of HF associated with underlying structural heart disease.Example:Dyspnea or fatigue due to left ventricular systolic dysfunction; asymptomatic patients who are undergoing treatment for prior symptoms of HF.Stage DPatients with advanced structural heart disease and marked symptoms of HF at rest despite maximal medical therapy and who require specialized interventions.Example: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.Karnofsky Performance Scale (KPS)The Karnofsky Performance Scale Index allows patients to be classified as to their functional impairment.
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