Please note that codes (CPT/HCPCS and ICD-10) have moved from LCDs to Billing & Coding Articles. 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; Dysphagia severe enough to prevent patient from continuing fluids/foods necessary to sustain life and patient does not receive artificial nutrition and hydration. ): 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. License to use CPT for any use not authorized herein must be obtained through the AMA, CPT Intellectual Property Services, AMA Plaza 330 N. Wabash Ave., Suite 39300, Chicago, IL 60611-5885. This can be used to compare effectiveness of different therapies and to assess the prognosis in individual patients. They are examples of findings that generally connote a poor prognosis. patients with marked limitation of activity; they are comfortable only at rest. 1994;73:2087-2098.Hurst JW, Morris DC, Alexander RW. Made a technical update to this LCD, to remove the empty Coding Information fields. Cancer. You are leaving the CMS MCD and are being redirected to the CMS MCD Archive that contains outdated (No Longer In Effect) Local Coverage Determinations and Articles, You are leaving the CMS MCD and are being redirected to, For services performed on or after 10/01/2015, For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 11/14/2019, AMA CPT / ADA CDT / AHA NUBC Copyright Statement. 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). In no event shall CMS be liable for direct, indirect, (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. copied without the express written consent of the AHA. However, the continuation of dialysis will significantly alter a patients prognosis, and thus potentially impact that individuals eligibility. Coverage for these patients may be approved if documentation otherwise supporting a less than six-month life expectancy is provided.Section 322 of BIPA amended section 1814(a) of the Social Security Act by clarifying that the certification of an individual who elects hospice "shall be based on the physician's or medical director's clinical judgment regarding the normal course of the individual's illness.'' 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. t'h0&@,41%;j4aJEG>wJ4RA0^c Decline in systolic blood pressure to below 90 or progressive postural hypotension, Venous, arterial or lymphatic obstruction due to local progression or metastatic disease, Laboratory (When available. The AMA assumes no liability for data contained or not contained herein. 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. Frequently no deficit in the following areas: Inability to perform complex tasks. 1991;46:M139-M144.de Haan R, Aaronson A, Limburg M, et al. No subjective complaints of memory deficit. Progression from an earlier stage of disease to metastatic disease with either:1. a continued decline in spite of therapy2. Made a technical update to this LCD to remove the empty Coding Information fields. These are quite variable and include: Stage 7 (Late Dementia) Very severe cognitive decline. 0000004098 00000 n CPT codes, descriptions and other data only are copyright 2022 American Medical Association. (1 and 2 should be present; factors from 3 will lend supporting documentation. Frequently continue to be able to distinguish familiar from unfamiliar persons in their environment. The A.S.P.E.N. (1 and 2 should be present. 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. They require no assistance with toileting and eating, but may have some difficulty choosing the proper clothing to wear. 1993;24:320- 327.Doyle D, Hanks G, Cherny N and Calman K. Oxford textbook of palliative medicine. All Rights Reserved (or such other date of publication of CPT). However, documentation expectations should comport with normal clinical documentation practices. Laboratory tests in protein-calorie malnutrition. Your MCD session is currently set to expire in 5 minutes due to inactivity. Federal government websites often end in .gov or .mil. Large anterior infarcts with both cortical and subcortical involvement; Upper urinary tract infection (pyelonephritis); Medicare Contractor Medical Directors' Hospice Workgroup, B. Friedman, M. Harwood, M. Shields. 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. accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the General Guidelines:Documentation certifying terminal status must contain enough information to support terminal status upon review. "JavaScript" disabled. Although guidelines applicable to certain disease categories are included, this LCD is applicable to all hospice patients. 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. 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. Clin Cardiol. While every effort has Consistent with Change Request 10901, all coding information, National coverage provisions, and Associated Information (Documentation Requirements, Utilization Guidelines) have been removed from the LCD and placed in the related Billing and Coding Article, A52830. If you do not agree with all terms and conditions set forth herein, click below on the button labeled "I do not accept" and exit from this computer screen. N. Christakis, E. Lamont. 0000060832 00000 n 0000016419 00000 n Inability to maintain hydration and caloric intake with 1 of the following: weight loss >10% in the last 6 months or >7. . The AMA does not directly or indirectly practice medicine or dispense medical services. Generally unaware of their surroundings, the year, the season, etc. 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. 0000040550 00000 n All billing and coding information was previously moved to the related Billing and Coding Article, A52830. Personality and emotional changes occur. At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. As used herein, "you" and "your" refer to you and any organization on behalf of which you are acting. 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. The document is broken into multiple sections. + 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. 0000040363 00000 n These should be documented in the clinical record. The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. 0000032947 00000 n Federal government websites often end in .gov or .mil. recipient email address(es) you enter. ), Chronic Kidney Disease (1 and either 2, 3 or 4 should be present. Significant congestive heart failure may be documented by an ejection fraction of less than or equal to 20%, but is not required if not already available. ; Obstructive hydrocephalus in patient who declines, or is not a candidate for, ventriculoperitoneal shunt. Please visit the. 2000;320:469-472.Crooks V, Waller S, Smith T, Hahn TJ. 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. 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 Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT for resale and/or license, transferring copies of CDT to any party not bound by this agreement, creating any modified or derivative work of CDT, or making any commercial use of CDT. Skip to main content Skip to navigation Skip to navigation. 0000008630 00000 n The FAST scale has 16 stages and sub-stages: Personal awareness of some functional decline. 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. Protein calorie malnutrition happens when you are not consuming enough protein and calories. At least two of the six characteristics are needed for the diagnosis of malnutrition. Frequently there is no speech at all - only grunting. Revision Explanation: Annual review no changes were made. They invariably know their own names and generally know their spouse's and children's names. National Government Services is not responsible for the continuing viability of Web site addresses listed below. 0000061858 00000 n Stroke or coma. Revision Explanation:Converted policy into new policy template that no longer includes coding section based on CR 10901. 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 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 50%. special, incidental, or consequential damages arising out of the use of such information, product, or process. Right heart failure (RHF) secondary to pulmonary disease (Cor pulmonale) (e.g., not secondary to left heart disease or valvulopathy). Medicare program. Examination by a neurologist within three months of assessment for hospice is advised, both to confirm the diagnosis and to assist with prognosis. Part II. You, your employees and agents are authorized to use CPT only as agreed upon with the AMA internally within your organization within the United States for the sole use by yourself, employees and agents. . Moribund; fatal processes progressing rapidly. The Social Security Act, Sections 1869(f)(2)(B) and 1862(l)(5)(D) define LCDs and provide information on the process. Use is limited to use in Medicare, Medicaid or other programs administered by the Centers for Medicare and Medicaid Services (CMS). Pain requiring increasing doses of major analgesics more than briefly. The views and/or positions Cachexia should have been listed as i. and not beside Albumin with ii, this has been corected. Stage2 (Forgetfulness)Very mild cognitive decline. Goal: 90%. 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. Hospice Eligibility Criteria Patient has a terminal illness with a life . 0000010879 00000 n 1973 May 12;1(7811):1041-2. Decline in clinical status guidelinesPatients 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. The 2023 edition of ICD-10-CM E46 became effective on October 1, 2022. E43 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. There is no regulation precluding patients on dialysis from electing Hospice care. ), (1 and either 2 or 3 should be present. Protein-calorie malnutrition (PCM) occurs when a child doesn't eat enough proteins and calories to meet nutritional needs. Right heart failure (RHF) secondary to pulmonary disease (Cor pulmonale) (e.g., not secondary to left heart disease or valvulopathy). 0000013372 00000 n The scope of this license is determined by the AMA, the copyright holder. Requires considerable assistance and frequent medical care. Although coding guidelines state that only one of these criteria needs to be met . 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. The American Hospital Association ("the AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. Experiences urinary and fecal incontinence. Stage 4 (Late Confusional)Moderate cognitive decline. Instructions for enabling "JavaScript" can be found here. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. E40 refers to Kwashiorkor is severe malnutrition with nutritional edema and dyspigmentation of skin and hair. (1 and 2 should be present, factors from 3 will lend supporting documentation. Progression of disease differs markedly from patient to patient. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely. 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. At the time of initial certification or recertification for hospice, the patient is or has been already optimally treated for heart disease or is not a candidate for a surgical procedure or has declined a procedure. ): Increasing pCO2 or decreasing pO2 or decreasing SaO2; Increasing calcium, creatinine or liver function studies; Increasing tumor markers (e.g. 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. You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. 3p=3t8@g3`PWYGQGYGQGYGQGYGQGo_e~kWB[({W}cw}QnoooooERa^*H78mQ_/.K 0 Some patients decline rapidly and die quickly; others progress more slowly. 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; 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. Note that two of the disease specific guidelines (HIV Disease, Stroke and Coma) establish a lower qualifying KPS or PPS. Nausea/vomiting poorly responsive to treatment. Patient declines further disease directed therapy. Creatinine clearance < 10 cc/min (<15 cc/min. Recurrent or intractable infections such as pneumonia, sepsis or upper urinary tract. . ), Liver DiseasePatients 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. HMn1>.`Ax! 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. Neither the United States Government nor its employees represent that use of Laboratory tests in protein-calorie malnutrition Lancet. For this reason, the history of the rate of progression in individual patients is important to obtain to predict prognosis. Extent and determinants of error in doctors prognoses in terminally ill patients: prospective cohort study. 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 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. Mild to moderate anxiety accompanies symptoms. 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. E. Lamont, N. Christakis. 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. CPT is a trademark of the American Medical Association (AMA). Some older versions have been archived. 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. recommending their use. Will be largely unaware of all recent events and experiences in their lives. Applicable FARS/HHSARS apply. 0000015750 00000 n By clicking below on the button labeled "I accept", you hereby acknowledge that you have read, understood and agreed to all terms and conditions set forth in this agreement. 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. Protein-Energy Malnutrition / diagnosis Serum Albumin / analysis Substances Amino Acids . descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work Coverage Indications, Limitations, and/or Medical Necessity. 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. Abnormal brain stem response 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. 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 Oxford University Press. Co-morbidities. CMS and its products and services are Requires assistance in choosing proper attire. @7Eq p[3gXsm!t;ON-:5,lX`9^n:myuT.sf~RG}|^no\x XP\w( Although guidelines applicable to certain disease categories are included, this LCD is applicable to all hospice patients. The AMA assumes no liability for data contained or not contained herein. Surface area of involvement of hemorrhage greater than or equal to 30% of cerebrum; Midline shift greater than or equal to 1.5 cm. Decline in Karnofsky Performance Status (KPS) or Palliative Performance Score (PPS) from <70% due to progression of disease. ), 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. 2003;20: 41-51.Ogle K, Mavis B, Wang T. Physicians and hospice care: attitudes, knowledge and referrals. Patient should demonstrate both rapid progression of ALS and critical nutritional impairment. Revision Explanation: Annual review, no changes made. The guidelines for LCD development are provided in Chapter 13 of the Medicare Program Integrity Manual. Revision Explanation: Annual review no changes made. Severely disabled; hospital admission is indicated although death not imminent. preparation of this material, or the analysis of information provided in the material. Serum creatinine > 8.0 mg/dl (>6.0 mg/dl for diabetics). %%EOF CMS believes that the Internet is an effective method to share LCDs that Medicare contractors develop. SERUM PROTEIN Please enable "JavaScript" and revisit this page or proceed with browsing CMS.gov with You acknowledge that the ADA holds all copyright, trademark and other rights in CDT. Muscle wasting with reduced strength and endurance; Continued active alcoholism (> 80 gm ethanol/day); Hepatitis C refractory to interferon treatment. 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. 0000000016 00000 n
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