0000011939 00000 n The amendment clarified that the certification is based on a clinical judgment regarding the usual course of a terminal illness, and recognizes the fact that making medical prognostications of life expectancy is not always exact. Baker D, Chin M, Cinquigrani M, et al. Some older versions have been archived. 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. 0000039481 00000 n The guidelines for LCD development are provided in Chapter 13 of the Medicare Program Integrity Manual. LCDs are specific to an item or service (procedure) and they define the specific diagnosis (illness or injury) for which the item or service is covered. without the written consent of the AHA. 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. The score can help determine which patients can be managed in the home and which should be admitted to a hospice unit. These should be documented in the clinical record.These changes in clinical variables apply to patients whose decline is not considered to be reversible. )Documentation should support the level of care being provided to the patient during the time period under review, i.e. Applicable FARS/HHSARS apply. Goal: 90%. ]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 ), Renal DiseasePatients 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.Acute Renal Failure (1 and either 2, 3 or 4 should be present. 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. 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. such information, product, or processes will not infringe on privately owned rights. THE UNITED STATES GOVERNMENT AND ITS EMPLOYEES ARE NOT LIABLE FOR ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN Personality and emotional changes occur. Factors from 3 will add supporting documentation. British Medical Journal. endstream endobj 707 0 obj <>/Filter/FlateDecode/Index[47 599]/Length 42/Size 646/Type/XRef/W[1 1 1]>>stream HUjI}iuU!v` "Y]I!T 3:NU^#={6: K]Sdl*B!XA-m2{gcm8n W)' fvtkW~e,y&2%!98kzb . For principle diagnoses in which severe protein-calorie malnutrition could be listed as a MCC, there must be documentation demonstrating additional Protein and calorie deficiencies alter insulin, growth hormone and cortisol levels, curtail hepatic function, and deplete mineral stores. 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. Applications are available at the AMA Web site, http://www.ama-assn.org/go/cpt. patient declines further disease directed therapyNote: Certain cancers with poor prognoses (e.g. The AMA does not directly or indirectly practice medicine or dispense medical services. Patient can no longer survive without some assistance. Please note that if you choose to continue without enabling "JavaScript" certain functionalities on this website may not be available. Although guidelines applicable to certain disease categories are included, this policy is applicable to all hospice patients. 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 0000032947 00000 n <]/Prev 527120/XRefStm 1970>> Pain requiring increasing doses of major analgesics more than briefly. Unspecified protein-calorie malnutrition. 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. Manifestations in more than one of the following areas: Objective evidence of memory deficit obtained only with an intensive interview. ): Increasing pCO2 or decreasing pO2 or decreasing SaO2; Increasing calcium, creatinine or liver function studies; Increasing tumor markers (e.g. 0 Protein Calorie Malnutrition Hospice Criteria. Dependence on assistance for two or more activities of daily living (ADLs): Co-morbidities although not the primary hospice diagnosis, the presence of disease such as the following, the severity of which is likely to contribute to a life expectancy of six months or less, should be considered in determining hospice eligibility. Medicare contractors are required to develop and disseminate Local Coverage Determinations (LCDs). 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. 26 Because the goal of dietary supplements is to provide adequate energy and protein. Any questions pertaining to the license or use of the CPT should be addressed to the AMA. Co-morbidities. Factors from 3 will add supporting documentation. Although coding guidelines state that only one of these criteria needs to be met . without the 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. Progressive inanition is documented by several measures such as 10% body weight loss, decreased albumin, and dysphagia leading to aspiration, among others. Unable to work; able to live at home and care for most personal needs; varying amount of assistance needed. Sign up to get the latest information about your choice of CMS topics in your inbox. 7500 Security Boulevard, Baltimore, MD 21244. Creatinine clearance < 10 cc/min (<15 cc/min. ), 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. %%EOF not endorsed by the AHA or any of its affiliates. In critically ill patients, these alterations can. Revision Explanation: Annual review no changes made. 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. ): 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. Sign up to get the latest information about your choice of CMS topics in your inbox. However, the continuation of dialysis will significantly alter a patients prognosis, and thus potentially impact that individuals eligibility. sensitive to and specic for protein-calorie malnutrition.4 Serum hepatic protein levels help the clinician to identify the sickest of patientsthose who may be more likely to develop malnutrition.1 It is imperative that the registered dietitian nutritionist in-terprets hepatic protein levels in the context of the patient's overall health A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. 0000160163 00000 n P rint Checklist: Documenting malnutrition (E41 and E43) This checklist is intended to provide healthcare providers with a reference for use when responding to medical documentation requests for services rendered and hospital admissions to treat malnutrition. CPT codes, descriptions and other data only are copyright 2022 American Medical Association. CMS and its products and services are not endorsed by the AHA or any of its affiliates. Coding professionals would use ICD-10-CM code E43 to report severe malnutrition, also known as starvation edema. The criteria refer to patients with various forms of advanced pulmonary disease who eventually follow a final common pathway for end stage pulmonary disease. CMS believes that the Internet is an effective method to share LCDs that Medicare contractors develop. Hepatic encephalopathy, refractory to treatment, or patient non-compliant; Recurrent variceal bleeding, despite intensive therapy. Patient declines further disease directed therapy. Copyright © 2022, the American Hospital Association, Chicago, Illinois. Requires assistance in choosing proper attire. The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. The AMA is a third party beneficiary to this Agreement. 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. Progression of disease as documented by worsening clinical status, symptoms, signs and laboratory results. required field. No specific number of variables must be met, but fewer of those listed first (more predictive) and more of those listed last (least predictive) would be expected to predict longevity of six months or less. This Agreement will terminate upon notice if you violate its terms. Laboratory tests in protein-calorie malnutrition. 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. 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. CPT is a trademark of the American Medical Association (AMA). The responsibility for the content of this file/product is with CMS and no endorsement by the AMA is intended or implied. 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. on this web site. The use of the Karnofsky Performance Scale in determining outcomes and risk in geriatric outpatients. 0000029167 00000 n 0000039022 00000 n 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. 0000061858 00000 n This LCD outlines coverage for hospice as indicated in the coverage and indications section. At the time of initial certification or recertification for hospice, the patient is or has been already optimally treated for heart disease, or are patients who are either not candidates for surgical procedures or who decline those procedures. Patient should demonstrate both rapid progression of ALS and critical nutritional impairment. Patients with dementia or Alzheimer's are eligible for hospice care when they show all of the following characteristics: 1. (1 and 2 should be present, factors from 3 will lend supporting documentation. Progressive decline in Functional Assessment Staging (FAST) for dementia (from 7A on the FAST). Please enable "JavaScript" and revisit this page or proceed with browsing CMS.gov with Some patients decline rapidly and die quickly; others progress more slowly. 1993;24:320- 327.Doyle D, Hanks G, Cherny N and Calman K. Oxford textbook of palliative medicine. ): 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. Proposed LCD document IDs begin with the letters "DL" (e.g., DL12345). 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. The page could not be loaded. Inability to maintain sufficient fluid and calorie intake in past 6 months (10% weight loss or albumin <2.5) . All billing and coding information was previously moved to the related Billing and Coding Article, A52830. 0000039330 00000 n J Gerontol. 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. 0000014780 00000 n Instructions for enabling "JavaScript" can be found here. 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. Examination by a neurologist within three months of assessment for hospice is advised, both to confirm the diagnosis and to assist with prognosis. If any physical activity is undertaken, discomfort is increased.) Frequently some disorientation to time (date, day of week, season, etc.) The A.S.P.E.N. Studies enrolling individuals with planned admissions (e.g. The amendment clarified that the certification is based on a clinical judgment regarding the usual course of a terminal illness, and recognizes the fact that making medical prognostications of life expectancy is not always exact.However, the amendment regarding the physician's clinical judgment does not negate the fact that there must be a basis for a certification. At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. 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. Applicable FARS/HHSARS apply. These guidelines are to be used in conjunction with the Non-disease specific baseline guidelines described in Part II. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. 0000037443 00000 n MACs are Medicare contractors that develop LCDs and process Medicare claims. It is intended to be used to identify any Medicare beneficiary whose current clinical status and anticipated progression of disease is more likely than not to result in a life expectancy of six months or less.Clinical variables with general applicability without regard to diagnosis, as well as clinical variables applicable to a limited number of specific diagnoses, are provided. Documentation of the applicable criteria listed under the Indications section of this policy would meet this requirement. Made a technical update to this LCD to remove the empty Coding Information fields. 5 $q`$Hx OmR1ShJ6yehl~"YQiy8{ f P?9G5RW\t 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. 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. 0000012375 00000 n 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. May have difficulty counting from 10, both backward and sometimes forward. 2001;134:1097-1143.McCluskey L, Houseman G. Medicare hospice referral criteria for patients with amyotrophic lateral sclerosis: a need for improvement. CDT is a trademark of the ADA. It was developed in British Columbia, Canada. (Documentation of serial decrease of FEV1>40 ml/year is objective evidence for disease progression, but is not necessary to obtain. Part II. End Users do not act for or on behalf of the CMS. 0000037874 00000 n 0000008075 00000 n the medical record and for coders to be aware of malnutrition as a potential diagnosis (ICD-10-CM codes E44.0, E44.1 and E46). (This value may be obtained from recent [within 3 months] hospital records.). 0000022017 00000 n presented in the material do not necessarily represent the views of the AHA. patients with slight, mild limitation of activity; they are comfortable with rest or with mild exertion. preparation of this material, or the analysis of information provided in the material. Requires assistance in complicated tasks such as handling finances, planning parties,etc. No memory deficit evident on clinical interviews. malnutrition (263.0: Malnutrition of a Moderate Degree) and severe malnutrition (262: Other Severe Protein Calorie Malnutrition). Please visit the, Progression of disease as documented by worsening clinical status, symptoms, signs and laboratory results.