Creatinine clearance < 10 cc/min (<15 cc/min. without the written consent of the AHA. 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. ALS tends to progress in a linear fashion over time. 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. These should be documented in the clinical record.These changes in clinical variables apply to patients whose decline is not considered to be reversible. 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. 0000037087 00000 n Your MCD session is currently set to expire in 5 minutes due to inactivity. Marasmus, or PEM without edema, is . For this reason, the history of the rate of progression in individual patients is important to obtain to predict prognosis. ge"^WOgr |___W+ tpIht=hozGC8 The use of the Karnofsky Performance Scale in determining outcomes and risk in geriatric outpatients. (This value may be obtained from recent [within 3 months] hospital records.). 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. descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work All rights reserved. CMS believes that the Internet is an effective method to share LCDs that Medicare contractors develop. Coding professionals would use ICD-10-CM code E43 to report severe malnutrition, also known as starvation edema. Please note that codes (CPT/HCPCS and ICD-10) have moved from LCDs to Billing & Coding Articles. Neither the United States Government nor its employees represent that use of While every effort has 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. British Medical Journal. While these characteristics are assessed along a continuum, rather than as discrete variables, they are useful in formulating and documenting a diagnosis of malnutrition. Please note that if you choose to continue without enabling "JavaScript" certain functionalities on this website may not be available. (Class IV patients with heart disease have an inability to carry on any physical activity without discomfort. 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. It places patients in one of four categories, based on how much they are limited during physical activity: patients with no limitation of activities; they suffer no symptoms from ordinary activities. An asterisk (*) indicates a The AMA does not directly or indirectly practice medicine or dispense medical services. LCD document IDs begin with the letter "L" (e.g., L12345). 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. 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. Reproduced with permission. General Guidelines:Documentation certifying terminal status must contain enough information to support terminal status upon review. Similarly, . endstream endobj 707 0 obj <>/Filter/FlateDecode/Index[47 599]/Length 42/Size 646/Type/XRef/W[1 1 1]>>stream Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by clicking below on the button labeled "I Accept". Diurnal rhythm frequently disturbed. 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. Medicare contractors are required to develop and disseminate Local Coverage Determinations (LCDs). In end-state ALS, two factors are critical in determining prognosis: ability to breathe, and to a lesser extent ability to swallow. Documentation of the applicable criteria listed under the Indications section of this policy would meet this requirement. Proposed LCD document IDs begin with the letters "DL" (e.g., DL12345). 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. 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. For this reason, the history of the rate of progression in individual patients is important to obtain to predict prognosis. Requires assistance dressing, bathing, and toileting. 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. J Palliative Medicine 2002; 5; 85-92. 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. Medicare contractors are required to develop and disseminate Local Coverage Determinations (LCDs). Serum creatinine > 8.0 mg/dl (>6.0 mg/dl for diabetics). The score can help determine which patients can be managed in the home and which should be admitted to a hospice unit. ]6o?7#qij]e]#mvb:~=y1\N(QhnX- }%h=#8At#ZRUpJK$\v&$&Np\KOI&'=%Oxu}j.bJBmv;]wy'.p|Wst]M3 \;y^zLGazW@ZzLgZ\$f29o"T=c(%/&Kp:,j{L Fu G 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. Right heart failure (RHF) secondary to pulmonary disease (Cor pulmonale) (e.g., not secondary to left heart disease or valvulopathy). (1 and 2 should be present. 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. Instructions for enabling "JavaScript" can be found here. forgetting where one has placed familiar objects; patient may have gotten lost when traveling to an unfamiliar location; co-workers become aware of patient's relatively low performance; word and name finding deficit becomes evident to intimates; patient may read a passage of a book and retain relatively little material; patient may demonstrate decreased facility in remembering names upon introduction to new people; patient may have lost or misplaced an object of value; concentration deficit may be evident on clinical testing. A52830 - Billing and Coding: Hospice: Determining Terminal Status. presented in the material do not necessarily represent the views of the AHA. Creatinine clearance <10 cc/min (< 15 cc/min for diabetics); or < 15cc/min (< 20cc/min for diabetics) with comorbidity of congestive heart failure. But specific entries can also call for an answer, such as an opinion by one team member or recovery of ADLS when they were part of the basis for the initial declaration of eligibility. > Flattening of affect and withdrawal from challenging situations occur. descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work 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. Another option is to use the Download button at the top right of the document view pages (for certain document types). Stage 1No cognitive decline. 0000000016 00000 n Accessed 01/16/2008.Schag CC, Heinrich RL, Ganz, PA. Karnofsky performance status revisited: Reliability, validity, and guidelines. E46 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. National Government Services is not responsible for the continuing viability of Web site addresses listed below. Also, you can decide how often you want to get updates. 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. Normal activity with effort; some signs or symptoms of disease. required field. Patients will be considered to be in the terminal stage of renal disease (life expectancy of six months or less) if they meet the following criteria. 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. E. Lamont, N. Christakis. 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%. Thus the overall rate of decline in each patient is fairly constant and predictable, unlike many other non-cancer diseases. Instructions for enabling "JavaScript" can be found here. There has been no change in coverage with this LCD revision. In end-state ALS, two factors are critical in determining prognosis: ability to breathe, and to a lesser extent ability to swallow. E40 refers to Kwashiorkor is severe malnutrition with nutritional edema and dyspigmentation of skin and hair. Unspecified severe protein-calorie malnutrition. 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. 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. 2004;7(1):47-53. Able to carry on normal activity; minor signs or symptoms of disease. <]/Prev 527120/XRefStm 1970>> 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. rVjh)aV 5%TO)i='@]Rx\EM~{m.3:t.UPu]*;bSj7U 0%q3- RJT40(?9O1UsFS3*CR|lf[`s40Q\r*u22,!5jc-+z ]o s 0000008075 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. Patient can no longer survive without some assistance. Factors from 3 will add supporting documentation. startxref 0000015750 00000 n Patient declines further disease directed therapy. This page displays your requested Local Coverage Determination (LCD). Your MCD session is currently set to expire in 5 minutes due to inactivity. )ndgM`.K3{daYpz:=~F~c~Cm& m& m& m& m#=#)XOz Some older versions have been archived. H\n0)B-FZBo>9X;frYQkh!:?^rt:wn/6]rO7go7c?[\zVi/6K]9bKCO1r{O=fU%=Xfey.)2"/g6_n. While not necessarily a contraindication to Hospice care, the decision to institute either artificial ventilation or artificial feeding may significantly alter six month prognosis. 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. )Documentation should support the level of care being provided to the patient during the time period under review, i.e. 0000029167 00000 n Clin Cardiol. No memory deficit evident on clinical interviews. 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 Current Dental Terminology © 2022 American Dental Association. 0000008742 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. The New York Heart Association (NYHA) Functional Classification provides a simple way of classifying heart disease (originally cardiac failure). Hence, it was concluded that albumin cannot be reliably used as a marker for diagnosing protein-calorie malnutrition . Use is limited to use in Medicare, Medicaid or other programs administered by the Centers for Medicare and Medicaid Services (CMS). Decline in Karnofsky Performance Status (KPS) or Palliative Performance Score (PPS) from <70% due to progression of disease. They are listed in order of their likelihood to predict poor survival, the most predictive first and the least predictive last. 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. The scope of this license is determined by the AMA, the copyright holder. 0000032947 00000 n Secondary Criteria Notes . Protein calorie malnutrition happens when you are not consuming enough protein and calories. There has been no change in coverage with this LCD revision. J Palliative Medicine 2002; 5; 73-84. ), 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. Chronic persistent diarrhea for one year; Absence of, or resistance to effective antiretroviral, chemotherapeutic and prophylactic drug therapy related specifically to HIV disease; Congestive heart failure, symptomatic at rest; Prothrombin time prolonged more than 5 seconds over control, or International Normalized Ratio (INR) >1.5; End stage liver disease is present and the patient shows at least one of the following: Ascites, refractory to treatment or patient non-compliant; Hepatorenal syndrome (elevated creatinine and BUN with oliguria). Protein calorie malnutrition is a type of undernutrition. Therefore, multiple clinical parameters are required to judge the progression of ALS. Muscle wasting with reduced strength and endurance; Continued active alcoholism (> 80 gm ethanol/day); Hepatitis C refractory to interferon treatment. 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. (1 and 2 should be present; factors from 3 will add supporting documentation. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or 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. Stage 3 (Early Confusional)Mild cognitive decline. Goal: 90%. Therefore, multiple clinical parameters are required to judge the progression of ALS. 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. patients with marked limitation of activity; they are comfortable only at rest. ), 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. Please note that codes (CPT/HCPCS and ICD-10) have moved from LCDs to Billing & Coding Articles. Hospice and primary care physicians: attitudes, knowledge, and barriers. Oxford University Press. . Systemic hypertension; coronary artery disease; diabetes mellitus; history of cardiotoxic drug therapy or alcohol abuse; personal history of rheumatic fever; family history of cardiomyopathy. Laboratory tests in protein-calorie malnutrition Lancet. Factors from 5 will lend supporting documentation. They require no assistance with toileting and eating, but may have some difficulty choosing the proper clothing to wear. Maybe it's the phenolic phytonutrients within flora which can be supporting, supported by way of proof that "sure vegetarian diets" appear to relieve "the severity of pores and skin illnesses" in adults with eczemathough in case you have a look at that quotation, it become a totally . CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. 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. The guidelines for LCD development are provided in Chapter 13 of the Medicare Program Integrity Manual. (1 and 2 should be present. A beneficiary may match a guideline, but by virtue of that individual having lived for a significantly prolonged period thereafter, he/she has shown that guideline to be inadequate to predict the appropriate terminal prognosis.ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult: Executive Summary A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1995 Guidelines for the Evaluation and Management of Heart Failure)Stages of Heart Failure (HF)Stage APatients at high risk of developing HF because of the presence of conditions that are strongly associated with the development of HF. 0000004185 00000 n 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. 0000006339 00000 n Note: 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.Non-Cancer DiagnosesAmyotrophic Lateral SclerosisGeneral Considerations: 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).Critically impaired respiratory function is as defined by: Severe nutritional insufficiency is defined as:Dysphagia with progressive weight loss of at least five percent of body weight with or without election for gastrostomy tube insertion.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.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. CEA, PSA); Progressively decreasing or increasing serum sodium or increasing serum potassium. t'h0&@,41%;j4aJEG>wJ4RA0^c 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 Nausea/vomiting poorly responsive to treatment. 2002;5:85-92.O'Toole DM. CMS and its products and services are not endorsed by the AHA or any of its affiliates. This LCD outlines coverage for hospice as indicated in the coverage and indications section. 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. Progression from an earlier stage of disease to metastatic disease with either: A continued decline in spite of therapy; or. The patient is classified as New York Heart Association (NYHA) Class IV and may have significant symptoms of heart failure or angina at rest. Unable to work; able to live at home and care for most personal needs; varying amount of assistance needed. The 2023 edition of ICD-10-CM E43 became effective on October 1, 2022. 0000003355 00000 n decreased knowledge of current and recent events; may exhibit some deficit in memory of one's personal history; concentration deficit elicited on serial subtractions; decreased ability to travel, handle finances, etc. The former can be managed by artificial ventilation, and the latter by gastrostomy or other artificial feeding, unless the patient has recurrent aspiration pneumonia. As used herein, "you" and "your" refer to you and any organization on behalf of which you are acting. ), Stroke and ComaPatients will be considered to be in the terminal stages of stroke or coma (life expectancy of six months or less) if they meet the following criteria:Stroke, The guidelines contained in this policy are intended to help providers determine when patients are appropriate for the Medicare Hospice benefit. Earliest clear-cut deficits. End User Point and Click Amendment: End Users do not act for or on behalf of the CMS. Life-threatening complications as demonstrated by one of the following characteristics occurring within the 12 months preceding initial hospice certification: Recurrent aspiration pneumonia (with or without tube feedings); Upper urinary tract infection, e.g., pyelonephritis; Recurrent fever after antibiotic therapy; Stage seven or beyond according to the Functional Assessment Staging Scale. 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. Before an LCD becomes final, the MAC publishes Proposed LCDs, which include a public comment period. Moribund; fatal processes progressing rapidly. "JavaScript" disabled. 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. Symptoms Include a number of symptoms, including nausea and vomiting, dyspnea, persisting cough, fatigue, decreased cognition, diarrhea, and progressive pain Signs 3p=3t8@g3`PWYGQGYGQGYGQGYGQGo_e~kWB[({W}cw}QnoooooERa^*H78mQ_/.K 0 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. 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. Also, the lack of certain documentation elements such as a tissue diagnosis for cancer will not create non-eligibility for the hospice benefit, but does necessitate other supportive documentation.Documentation submitted may include information from periods of time that fall outside the billing period currently under review. endstream endobj 660 0 obj <>stream NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). Measurement of quality of life in patients with lung cancer in multicenter trials of new therapies. End User Point and Click Amendment: Healthcare providers retain responsibility to submit complete and accurate. Large anterior infarcts with both cortical and subcortical involvement. However, some are clearly more predictive of a poor prognosis than others; significant ongoing weight loss is a strong predictor, while decreased functional status is less so. 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). British Medical Journal 2000; 320; 469-472. Although guidelines applicable to certain disease categories are included, this policy is applicable to all hospice patients. If your session expires, you will lose all items in your basket and any active searches. Protein Calorie Malnutrition Hospice Criteria. Cancer. 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. 0000039481 00000 n The document is broken into multiple sections. Part III. Some patients may not meet these guidelines, yet still have a life expectancy of six months or less. 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. 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. Normal activity & work No evidence of disease, Normal activity & work Some evidence of disease, Normal activity with effort Some evidence of disease, Unable Normal Job/Work Significant disease, Unable hobby/house work Significant disease, Unable to do most activity Extensive disease, Unable to do any activity Extensive disease, Detailed Description of Each of the 7 Stages. Decline in systolic blood pressure to below 90 or progressive postural hypotension; Venous, arterial or lymphatic obstruction due to local progression or metastatic disease; Increasing pCO2 or decreasing pO2 or decreasing SaO2; Increasing calcium, creatinine or liver function studies; Increasing tumor markers (e.g. 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. The 2023 edition of ICD-10-CM E46 became effective on October 1, 2022. Progressive stage 3-4 pressure ulcers in spite of optimal care. authorized with an express license from the American Hospital Association. Right heart failure (RHF) secondary to pulmonary disease (Cor pulmonale) (e.g., not secondary to left heart disease or valvulopathy). THE INFORMATION, PRODUCT, OR PROCESSES DISCLOSED HEREIN. ACC/AHA Guidelines for the evaluation and management of chronic heart failure in the adult: executive summary, a report of the American college of cardiology/American heart association task force on practice guidelines (committee to revise the 1995 guidelines of the evaluation and management of heart failure).
