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. Progression of disease as documented by worsening clinical status, symptoms, signs and laboratory results. AbstractMedicare 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. Documentation of 3, 4, and 5, will lend supporting documentation. trailer Estimated glomerular filtration rate (GFR) <10 ml/min. Right heart failure (RHF) secondary to pulmonary disease (Cor pulmonale) (e.g., not secondary to left heart disease or valvulopathy). 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. 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. 0000006339 00000 n Although ALS usually presents in a localized anatomical area, the location of initial presentation does not correlate with survival time. However, documentation expectations should comport with normal clinical documentation practices. 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. Progression of disease differs markedly from patient to patient. Neither the United States Government nor its employees represent that use of There are multiple ways to create a PDF of a document that you are currently viewing. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816. 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. 0000012920 00000 n They are examples of findings that generally connote a poor prognosis. Please do not use this feature to contact CMS. 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. Documentation of the following factors will support eligibility for hospice care: 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 (< 400 ml/day) and urine sodium concentration < 10 mEq/l); Hepatic encephalopathy, refractory to treatment, or patient non-compliant; Recurrent variceal bleeding, despite intensive therapy. Lab testing is not required to establish hospice eligibility. Your MCD session is currently set to expire in 5 minutes due to inactivity. Coma Primary Criteria Patient with any 3 of the following on day three of coma: 1. Before an LCD becomes final, the MAC publishes Proposed LCDs, which include a public comment period. xref The scope of this license is determined by the AMA, the copyright holder. Documentation of the applicable criteria listed under the Indications section of this policy would meet this requirement. You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement. 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. The document is broken into multiple sections. 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. 0000015606 00000 n (1 and 2 should be present. If any physical activity is undertaken, discomfort is increased.) Stage 6 (Middle Dementia) Severe cognitive decline.May occasionally forget the name of the spouse upon whom they are entirely dependent for survival. 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. Applicable FARS/HHSARS apply. 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. 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). 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. 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. required field. Also, you can decide how often you want to get updates. Include supporting events such as a change in the level of activities of daily living, recent hospitalizations, and the known date of death (if you are billing for a period of time prior to the billing period in which death occurred. Dysphagia leading to recurrent aspiration and/or inadequate oral intake documented by decreasing food portion consumption. AJ Hospice & Palliative Care. (1 and 2 should be present, factors from 3 will lend supporting documentation. This is the American ICD-10-CM version of E46 - other international versions of ICD-10 E46 may differ. ): Increasing pCO2 or decreasing pO2 or decreasing SaO2; Increasing calcium, creatinine or liver function studies; Increasing tumor markers (e.g. This can be used to compare effectiveness of different therapies and to assess the prognosis in individual patients. 0000003910 00000 n 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. Factors from 5 will lend supporting documentation. . They may be incorporated by specific reference as part (or all) of the indication for recertification. Creatinine clearance <10 cc/min (< 15 cc/min for diabetics); or < 15cc/min (< 20cc/min for diabetics) with comorbidity of congestive heart failure. Patients with congestive heart failure or angina should meet the criteria for the New York Heart Association (NYHA) Class IV. Made a technical update to this LCD, to remove the empty Coding Information fields. Dyspnea with increasing respiratory rate; Nausea/vomiting poorly responsive to treatment; Pain requiring increasing doses of major analgesics more than briefly. Appropriate concern regarding symptoms. 1999;22(6):385-90.Lamont E, Christakis N. Prognostic disclosure to patients with cancer near the end of life. Made a technical update to this LCD to remove the empty Coding Information fields. Stage2 (Forgetfulness)Very mild cognitive decline. 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 AMA assumes no liability for data contained or not contained herein. Requires assistance dressing, bathing, and toileting. recipient email address(es) you enter. 0000017875 00000 n 0000014923 00000 n 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. Coverage Indications, Limitations, and/or Medical Necessity. The Social Security Act, Sections 1869(f)(2)(B) and 1862(l)(5)(D) define LCDs and provide information on the process. MACs are Medicare contractors that develop LCDs and process Medicare claims. 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. All Rights Reserved. Current Dental Terminology © 2022 American Dental Association. 0000016419 00000 n The records should include observations and data, not merely conclusions. The Global Malnutrition Composite Score (GMCS) electronic clinical quality measure is comprised of four components reflecting inpatient malnutrition identification and care. Karnofsky Performance Status (KPS) or Palliative Performance Scale (PPS) of < 40% . Pain requiring increasing doses of major analgesics more than briefly. 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". (1 and 2 should be present; factors from 3 will add supporting documentation. The AMA does not directly or indirectly practice medicine or dispense medical services. CMS believes that the Internet is an effective method to share LCDs that Medicare contractors develop. presented in the material do not necessarily represent the views of the AHA. not endorsed by the AHA or any of its affiliates. E46 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. CPT codes, descriptions and other data only are copyright 2022 American Medical Association. Creatinine clearance < 10 cc/min (<15 cc/min. 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. Use is limited to use in Medicare, Medicaid or other programs administered by the Centers for Medicare and Medicaid Services (CMS). For example, severe protein-calorie malnutrition cannot be considered a MCC for the principle diagnosis of "Failure to Thrive" because the two conditions are too similar. 0000002163 00000 n 0000001970 00000 n Protein-Energy Malnutrition / diagnosis Serum Albumin / analysis Substances Amino Acids . No fee schedules, basic unit, relative values or related listings are included in CPT. There are multiple ways to create a PDF of a document that you are currently viewing. 2001;104:2996-3007. J Palliative Medicine. An asterisk (*) indicates a You acknowledge that the ADA holds all copyright, trademark and other rights in CDT. There has been no change in coverage with this LCD revision. You can use the Contents side panel to help navigate the various sections. If your session expires, you will lose all items in your basket and any active searches. Proposed LCD document IDs begin with the letters "DL" (e.g., DL12345). The lower the Karnofsky score, the worse the survival for most serious illnesses.KARNOFSKY PERFORMANCE STATUS SCALE DEFINITIONS RATING (%) CRITERIA. endstream endobj 659 0 obj <>stream ), 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. If you are experiencing any technical issues related to the search, selecting the 'OK' button to reset the search data should resolve your issues. Requires assistance in complicated tasks such as handling finances, planning parties,etc. The Centers for Medicare & Medicaid Services (CMS), the federal agency responsible for administration of the Medicare, Medicaid Frequently some disorientation to time (date, day of week, season, etc.) For this reason, the history of the rate of progression in individual patients is important to obtain to predict prognosis. 0000037874 00000 n All billing and coding information was previously moved to the related Billing and Coding Article, A52830. 0000040523 00000 n Cachexia should have been listed as i. and not beside Albumin with ii, this has been corected. Some older versions have been archived. 0000061858 00000 n CDT is a trademark of the ADA. ), 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.) This is the American ICD-10-CM version of E43 - other international versions of ICD-10 E43 may differ. The Tracking Sheet modal can be closed and re-opened when viewing a Proposed LCD. This bibliography presents those sources that were obtained during the development of this policy. 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.