copied without the express written consent of the AHA. 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. 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. 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. 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. 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. Similarly, . Documentation of the applicable criteria listed under the Indications section of this policy would meet this requirement. Annals of Internal Medicine 2001; 134; 1097-1143. (1 and 2 should be present. Note: This section is specific for Alzheimers disease and Related Disorders, and is not appropriate for other types of dementia.Heart DiseasePatients 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. ]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 Although guidelines applicable to certain disease categories are included, this LCD is applicable to all hospice patients. The score can help determine which patients can be managed in the home and which should be admitted to a hospice unit. Some older versions have been archived. (Class IV patients with heart disease have an inability to carry on any physical activity. without the written consent of the AHA. Please review and accept the agreements in order to view Medicare Coverage documents, which may include licensed information and codes. 0000011939 00000 n 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. While most healthcare facilities still follow the previous ASPEN criteria, in 2018, ASPEN joined with the . endstream endobj 660 0 obj <>stream 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). 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. While not necessarily a contraindication to Hospice Care, the decision to institute either artificial ventilation or artificial feeding will significantly alter six-month prognosis. Thus the overall rate of decline in each patient is fairly constant and predictable, unlike many other non-cancer diseases. Revision Explanation: Annual review no changes made. Unspecified protein-calorie malnutrition. Recommendation: Target blood glucose range of 140 - 180 mg\dL for the general ICU population. ), 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.) ALS tends to progress in a linear fashion over time. (Documentation of serial decrease of FEV1>40 ml/year is objective evidence for disease progression, but is not necessary to obtain. 0000040363 00000 n %%EOF For this reason, the history of the rate of progression in individual patients is important to obtain to predict prognosis. While every effort has The page could not be loaded. 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. ), 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. For principle diagnoses in which severe protein-calorie malnutrition could be listed as a MCC, there must be documentation demonstrating additional Lab testing is not required to establish hospice eligibility. The CMS.gov Web site currently does not fully support browsers with . 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. The Global Malnutrition Composite Score (GMCS) electronic clinical quality measure is comprised of four components reflecting inpatient malnutrition identification and care. 0000037955 00000 n 0000004710 00000 n 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. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely. You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. authorized with an express license from the American Hospital Association. The responsibility for the content of this file/product is with CMS and no endorsement by the AMA is intended or implied. Patients will be considered to be in the terminal stage of dementia (life expectancy of six months or less) if they meet the following criteria. (1 and 2 should be present; factors from 3 will lend supporting documentation. 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. Dr Reisberg has also shown that the decline typical of Alzheimer's disease is the flip side of normal skill acquisition by infants, children, and young adults: Available from ElderCare Online http://www.ec-online.net/ Barry Reisberg, MD 1984. of every MCD page. These materials contain Current Dental Terminology (CDTTM), copyright© 2022 American Dental Association (ADA). ), Increasing pCO2 or decreasing pO2 or decreasing SaO2, Increasing calcium, creatinine or liver function studies, Progressively decreasing or increasing serum sodium or increasing serum potassium. Other clinical variables not on this list may support a six-month or less life expectancy. 0000013895 00000 n The AMA does not directly or indirectly practice medicine or dispense medical services. Symptoms of heart failure or of the anginal syndrome may be present even at rest. 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. They would use ICD-10-CM code E42 to report severe protein-calorie malnutrition with signs of both kwashiorkor and marasmus. Protein-calorie malnutrition (PCM) occurs when a child doesn't eat enough proteins and calories to meet nutritional needs. Other clinical variables not on this list may support a six-month or less life expectancy. Protein calorie malnutrition, nutritional intervention and personalized cancer care Authors Anju Gangadharan 1 , Sung Eun Choi 2 , Ahmed Hassan 1 , Nehad M Ayoub 3 , Gina Durante 4 , Sakshi Balwani 1 , Young Hee Kim 4 , Andrew Pecora 5 , Andre Goy 5 , K Stephen Suh 1 Affiliations An asterisk (*) indicates a 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. 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. The guidelines for LCD development are provided in Chapter 13 of the Medicare Program Integrity Manual. Although ALS usually presents in a localized anatomical area, the location of initial presentation does not correlate with survival time. ): Patients awaiting liver transplant who otherwise fit the above criteria may be certified for the Medicare hospice benefit, but if a donor organ is procured, the patient should be discharged from hospice.F. Muscle wasting with reduced strength and endurance; Continued active alcoholism (>80 gm ethanol/day); Hepatitis C refractory to interferon treatment. 2000;320:469-472.Crooks V, Waller S, Smith T, Hahn TJ. This policy describes guidelines to be used by Home Health & Hospice (HH&H) MAC in reviewing hospice claims and by hospice providers to determine eligibility of beneficiaries for hospice benefits. Able to carry on normal activity; minor signs or symptoms of disease. 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. Patient should demonstrate both rapid progression of ALS and life-threatening complications. 0000003910 00000 n ge"^WOgr |___W+ tpIht=hozGC8 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. 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. ): Increasing pCO2 or decreasing pO2 or decreasing SaO2; Increasing calcium, creatinine or liver function studies; Increasing tumor markers (e.g. Stage 4 (Late Confusional)Moderate cognitive decline. The guidelines for LCD development are provided in Chapter 13 of the Medicare Program Integrity Manual. (Optimally treated means that patients who are not on vasodilators have a medical reason for refusing these drugs, e.g., hypotension or renal disease.). 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). 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. Requires assistance in choosing proper attire. Creatinine clearance < 10 cc/min (<15 cc/min. As used herein, "you" and "your" refer to you and any organization on behalf of which you are acting. Therefore, multiple clinical parameters are required to judge the progression of ALS. Progressive malnutrition, muscle wasting with dec. strength, ongoing alcoholism (>80 gm . In critically ill patients, these alterations can. Although ALS usually presents in a localized anatomical area, the location of initial presentation does not correlate with survival time. The Tracking Sheet modal can be closed and re-opened when viewing a Proposed LCD. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or 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. Speech ability declines to about a half-dozen intelligible words. Severe chronic lung disease as documented by both a and b: Disabling dyspnea at rest, poorly or unresponsive to bronchodilators, resulting in decreased functional capacity, e.g., bed to chair existence, fatigue, and cough; (Documentation of Forced Expiratory Volume in One Second (FEV1), after bronchodilator, less than 30% of predicted is objective evidence for disabling dyspnea, but is not necessary to obtain. endstream endobj 657 0 obj <> endobj 658 0 obj <>stream 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). History of increasing ER visits, hospitalizations, or physician visits related to the hospice primary diagnosis prior to election of the hospice benefit. AJ Hospice & Palliative Care, 2003; 20; 41-51. 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. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be "JavaScript" disabled. The patient is classified as New York Heart Association (NYHA) Class IV and may have significant symptoms of heart failure or angina at rest. Neither the United States Government nor its employees represent that use of AJ Hospice & Palliative Care. Some patients may not meet these guidelines, yet still have a life expectancy of six months or less. 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. 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. Baseline data may be established on admission to hospice or by using existing information from records. If any physical activity is undertaken, discomfort is increased.) required field. Also, you can decide how often you want to get updates. Inability to maintain sufficient fluid and calorie intake with 10% weight loss during the previous six months or serum albumin <2.5 gm/dl . It does not mean, however, that meeting the guideline is obligatory. 0000060832 00000 n authorized with an express license from the American Hospital Association. J Gerontol. MACs are Medicare contractors that develop LCDs and process Medicare claims. 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. British Medical Journal. preparation of this material, or the analysis of information provided in the material. National Government Services is not responsible for the continuing viability of Web site addresses listed below. This page displays your requested Local Coverage Determination (LCD). Stage2 (Forgetfulness)Very mild cognitive decline. 0000014923 00000 n Abnormal brain stem response Estimated glomerular filtration rate (GFR) <10 ml/min. and the State Children's Health Insurance Programs, contracts with certain organizations to assist in the administration of the Please note that if you choose to continue without enabling "JavaScript" certain functionalities on this website may not be available. Requires considerable assistance and frequent medical care. Prognostic disclosure to patients with cancer near end of life. R2Revision Effective: N/ARevision Explanation: Annual review no changes made. ; Obstructive hydrocephalus in patient who declines, or is not a candidate for, ventriculoperitoneal shunt. No fee schedules, basic unit, relative values or related listings are included in CPT. 0000002894 00000 n Measurement of quality of life in patients with lung cancer in multicenter trials of new therapies. Documentation of 3, 4, and 5, will lend supporting documentation. Current Dental Terminology © 2022 American Dental Association. Laboratory tests in protein-calorie malnutrition. The Palliative Performance Scale (PPS) is a modification of the Karnofsky Performance Scale intended for evaluating patients requiring palliative care. Protein Calorie Malnutrition Hospice Criteria. West J Med. This is the American ICD-10-CM version of E43 - other international versions of ICD-10 E43 may differ. CPT is a trademark of the American Medical Association (AMA). 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. Federal government websites often end in .gov or .mil. descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work While these characteristics are assessed along a continuum, rather than as discrete variables, they are useful in formulating and documenting a diagnosis of malnutrition. All verbal abilities are lost. All Rights Reserved. Applicable Federal Acquisition Regulation Clauses (FARS)/Department of Defense Federal Acquisition Regulation supplement (DFARS) Restrictions Apply to Government Use. Before sharing sensitive information, make sure you're on a federal government site. 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 Tracking Sheet modal can be closed and re-opened when viewing a Proposed LCD. J Palliative Medicine 2002; 5; 85-92. 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. Nausea/vomiting poorly responsive to treatment. 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. Experiences urinary and fecal incontinence. In end-state ALS, two factors are critical in determining prognosis: ability to breathe, and to a lesser extent ability to swallow. Therefore, multiple clinical parameters are required to judge the progression of ALS. The CMS.gov Web site currently does not fully support browsers with guidelines for diagnosing malnutrition, which looked at six characteristics, were first proposed in 2009 . THE INFORMATION, PRODUCT, OR PROCESSES DISCLOSED HEREIN. At least two of the six characteristics are needed for the diagnosis of malnutrition. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material. 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. 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. 0000037874 00000 n 26 Because the goal of dietary supplements is to provide adequate energy and protein. Part I. A52830 - Billing and Coding: Hospice: Determining Terminal Status. descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work