1994;73:2087-2098.Hurst JW, Morris DC, Alexander RW. Decline in Karnofsky Performance Status (KPS) or Palliative Performance Score (PPS) from <70% due to progression of disease. 0000040550 00000 n 2001;104:2996-3007. Stroke. 0000038836 00000 n The guidelines for LCD development are provided in Chapter 13 of the Medicare Program Integrity Manual. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816. Protein-energy malnutrition (PEM) is classically described as 1 of 2 syndromes, marasmus and kwashiorkor, depending on the presence or absence of edema. Your MCD session is currently set to expire in 5 minutes due to inactivity. 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. Factors from 5 will lend supporting documentation. 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. 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. Baseline data may be established on admission to hospice or by using existing information from records. In such cases, it is important for providers to meticulously document the factors which specify the individuals terminal prognosis.There are also patients who match a guideline at the start of hospice care, and who continue to do so for a prolonged period, e.g., greater than six months. 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. Abnormal brain stem response No fee schedules, basic unit, relative values or related listings are included in CPT. required field. ), (1 and either 2 or 3 should be present. Normal activity with effort; some signs or symptoms of disease. (1 and 2 should be present. In no event shall CMS be liable for direct, indirect, Neurologic disease (CVA, ALS, MS, Parkinsons), Refractory severe autoimmune disease (e.g. Moribund; fatal processes progressing rapidly. Recurrent or intractable serious infections such as pneumonia, sepsis or pyelonephritis; Weight loss of at least 10% body weight in the prior six months, 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; Observation of ill-fitting clothes, decrease in skin turgor, increasing skin folds or other observation of weight loss in a patient without documented weight; Dysphagia leading to recurrent aspiration and/or inadequate oral intake documented by decreasing food portion consumption. Personality and emotional changes occur. Applicable FARS\DFARS Restrictions Apply to Government Use. 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). No memory deficit evident on clinical interviews. Pain requiring increasing doses of major analgesics more than briefly. An official website of the United States government. Protein and calorie deficiencies alter insulin, growth hormone and cortisol levels, curtail hepatic function, and deplete mineral stores. (Optimally treated means that patients who are not on vasodilators have a medical reason for refusing these drugs, e.g., hypotension or renal disease.). Please enable "JavaScript" and revisit this page or proceed with browsing CMS.gov with If any physical activity is undertaken, discomfort is increased.) Language quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. Dysphagia leading to recurrent aspiration and/or inadequate oral intake documented by decreasing food portion consumption. J Palliative Medicine 2002; 5; 73-84. 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. 2004;7(1):47-53. Instructions for enabling "JavaScript" can be found here. 0000037955 00000 n 0000039022 00000 n CMS and its products and services are 0000009368 00000 n Please enable "JavaScript" and revisit this page or proceed with browsing CMS.gov with When performing a clinical validation review, start by confirming the presence of malnutrition and then apply validation to the level of severity. 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. 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.'' Evaluating cancer patients for rehabilitation potential. J Gerontol. been made to provide accurate and complete information, CMS does not guarantee that there are no errors in the information displayed 0000029167 00000 n (1 and 2 should be present. + LCDs outline how the contractor will review claims to ensure that the services provided meet Medicare coverage requirements. 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; 0000002894 00000 n 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. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials. License to use CDT for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Laboratory tests in protein-calorie malnutrition Lancet. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. 844-4CHILDRENS (844-424-4537) 844-424-4537; Patient Login (MyChart . The FAST scale has 16 stages and sub-stages: Personal awareness of some functional decline. All rights reserved. If your session expires, you will lose all items in your basket and any active searches. Applicable Federal Acquisition Regulation Clauses (FARS)/Department of Defense Federal Acquisition Regulation supplement (DFARS) Restrictions Apply to Government Use. Instructions for enabling "JavaScript" can be found here. 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. Patients with congestive heart failure or angina should meet the criteria for the New York Heart Association (NYHA) Class IV. Comatose patients with any 3 of the following on day three of coma: Documentation of medical complications, in the context of progressive clinical decline, within the previous 12 months, which support a terminal prognosis: Documentation of diagnostic imaging factors which support poor prognosis after stroke include: Infratentorial: greater than or equal to 20 ml. It places patients in one of four categories, based on how much they are limited during physical activity:Class I: patients with no limitation of activities; they suffer no symptoms from ordinary activities.Class II: patients with slight, mild limitation of activity; they are comfortable with rest or with mild exertion.Class III: patients with marked limitation of activity; they are comfortable only at rest.Class IV: patients who should be at complete rest, confined to bed or chair; any physical activity brings on discomfort and symptoms occur at rest.Palliative Performance ScaleThe Palliative Performance Scale (PPS) is a modification of the Karnofsky Performance Scale intended for evaluating patients requiring palliative care. Creatinine clearance < 10 cc/min (<15 cc/min. 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. . 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. Disabled; requires special care and assistance. Persons at this stage retain knowledge of many major facts regarding themselves and others. Skip to main content Skip to navigation Skip to navigation. presented in the material do not necessarily represent the views of the AHA. Generally unaware of their surroundings, the year, the season, etc. Lab testing is not required to establish hospice eligibility. ge"^WOgr |___W+ tpIht=hozGC8 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. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or 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. Please do not use this feature to contact CMS. The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. 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. Some patients decline rapidly and die quickly; others progress more slowly. 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. Please visit the. Nausea/vomiting poorly responsive to treatment. License to use CDT for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. 0000037804 00000 n Baseline data may be established on admission to hospice or by using existing information from records. 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. 0000012375 00000 n (1 and 2 should be present; factors from 3 will add supporting documentation. No subjective complaints of memory deficit. CMS and its products and services are not endorsed by the AHA or any of its affiliates. CPT codes, descriptions and other data only are copyright 2022 American Medical Association. 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. 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. These should be documented in the clinical record. Will be largely unaware of all recent events and experiences in their lives. 0000002310 00000 n Muscle wasting with reduced strength and endurance; Continued active alcoholism (> 80 gm ethanol/day); Hepatitis C refractory to interferon treatment. All Rights Reserved. The criteria refer to patients with various forms of advanced pulmonary disease who eventually follow a final common pathway for end stage pulmonary disease. 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 The scope of this license is determined by the AMA, the copyright holder. 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. Proposed LCD document IDs begin with the letters "DL" (e.g., DL12345). End Users do not act for or on behalf of the CMS. 0000038553 00000 n ), 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. 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. General Guidelines:Documentation certifying terminal status must contain enough information to support terminal status upon review. 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. 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. Examination by a neurologist within three months of assessment for hospice is advised, both to confirm the diagnosis and to assist with prognosis. No fee schedules, basic unit, relative values or related listings are included in CPT. However, documentation expectations should comport with normal clinical documentation practices. 0000015750 00000 n The criteria refer to patients with various forms of advanced pulmonary disease who eventually follow a final common pathway for end stage pulmonary disease. Patient should demonstrate both rapid progression of ALS and life-threatening complications. 0000039400 00000 n The AMA does not directly or indirectly practice medicine or dispense medical services. In end-state ALS, two factors are critical in determining prognosis: ability to breathe, and to a lesser extent ability to swallow. Unable to work; able to live at home and care for most personal needs; varying amount of assistance needed. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. K. Ogle, B. Mavis, G. Wyatt. Unspecified severe protein-calorie malnutrition. 0000032947 00000 n 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. 0000060832 00000 n National Government Services is not responsible for the continuing viability of Web site addresses listed below. 0000037443 00000 n recommending their use. Mild protein-calorie malnutrition (weight for age 75-89% of standard) Protein calorie malnutrition, mild (gomez 75-90% s ICD-10-CM E44.1 is grouped within Diagnostic Related Group (s) (MS-DRG v40.0): 640 Miscellaneous disorders of nutrition, metabolism, fluids and electrolytes with mcc 0000007316 00000 n A: Determining when to query for a malnutrition diagnosis can be very tricky. 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. Able to carry on normal activity; minor signs or symptoms of disease. 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. ): Increasing pCO2 or decreasing pO2 or decreasing SaO2; Increasing calcium, creatinine or liver function studies; Increasing tumor markers (e.g. ), 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.) 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). SERUM PROTEIN Estimated glomerular filtration rate (GFR) <10 ml/min. ), 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. 0000015606 00000 n The Tracking Sheet modal can be closed and re-opened when viewing a Proposed LCD. CMS and its products and services are not endorsed by the AHA or any of its affiliates. Some older versions have been archived. for diabetics); or < 15cc/min (< 20cc/min for diabetics) with comorbidity of congestive heart failure. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT. Documentation of 3, 4, and 5, will lend supporting documentation.). 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. Please note that codes (CPT/HCPCS and ICD-10) have moved from LCDs to Billing & Coding Articles. descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work Surface area of involvement of hemorrhage 30% of cerebrum; Obstructive hydrocephalus in patient who declines, or is not a candidate for, ventriculoperitoneal shunt. 0000003355 00000 n authorized with an express license from the American Hospital Association. 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. 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. Sign up to get the latest information about your choice of CMS topics in your inbox. Part III. Unable to care for self; requires equivalent of institutional or hospital care; disease may be progressing rapidly. AHA copyrighted materials including the UB‐04 codes and guidelines for diagnosing malnutrition, which looked at six characteristics, were first proposed in 2009 . 0000011336 00000 n Protein-calorie malnutrition (PCM) occurs when a child doesn't eat enough proteins and calories to meet nutritional needs. Use is limited to use in Medicare, Medicaid or other programs administered by the Centers for Medicare and Medicaid Services (CMS). The former can be managed by artificial ventilation, and the latter by gastrostomy or other artificial feeding, unless the patient has recurrent aspiration pneumonia. descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work 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. Measuring quality of life in stroke. Current Dental Terminology © 2022 American Dental Association. Other clinical variables not on this list may support a six-month or less life expectancy. THE UNITED STATES GOVERNMENT AND ITS EMPLOYEES ARE NOT LIABLE FOR ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN 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. Lupus or Rheumatoid Arthritis). They may be incorporated by specific reference as part (or all) of the indication for recertification. Coding professionals would use ICD-10-CM code E43 to report severe malnutrition, also known as starvation edema. Baker D, Chin M, Cinquigrani M, et al. "JavaScript" disabled. 0000040080 00000 n ), 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. It does not mean, however, that meeting the guideline is obligatory. Progressive stage 3-4 pressure ulcers in spite of optimal care. Progression from an earlier stage of disease to metastatic disease with either:1. a continued decline in spite of therapy2. MACs are Medicare contractors that develop LCDs and process Medicare claims. special, incidental, or consequential damages arising out of the use of such information, product, or process. 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 DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. Although ALS usually presents in a localized anatomical area, the location of initial presentation does not correlate with survival time. Secondary Criteria Notes . Lab testing is not required to establish hospice eligibility. Factors from 4 will lend supporting documentation. ), Hypoxemia at rest on room air, as evidenced by pO2 less than or equal to 55 mmHg, or oxygen saturation less than or equal to 88%, determined either by arterial blood gases or oxygen saturation monitors, (these values may be obtained from recent hospital records) OR hypercapnia, as evidenced by pCO2 greater than or equal to 50 mmHg. 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.'' 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. Patient can no longer survive without some assistance. 0000003947 00000 n 0000003984 00000 n All Rights Reserved. documentation. They are examples of findings that generally connote a poor prognosis. 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. CDT is a trademark of the ADA. 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. The AMA assumes no liability for data contained or not contained herein. The Centers for Medicare & Medicaid Services (CMS), the federal agency responsible for administration of the Medicare, Medicaid The views and/or positions CEA, PSA); Progressively decreasing or increasing serum sodium or increasing serum potassium. 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. The views and/or positions (1 and 2 should be present; factors from 3 will add supporting documentation. 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]).