protein calorie malnutrition hospice criteria

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. This email will be sent from you to the Right heart failure (RHF) secondary to pulmonary disease (Cor pulmonale) (e.g., not secondary to left heart disease or valvulopathy). 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 Palliative Performance Scale (PPS) is a modification of the Karnofsky Performance Scale intended for evaluating patients requiring palliative care. 0000006339 00000 n "JavaScript" disabled. 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 page could not be loaded. 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. Please note that if you choose to continue without enabling "JavaScript" certain functionalities on this website may not be available. Unspecified severe protein-calorie malnutrition. Factors from 3 will add supporting documentation. Lupus or Rheumatoid Arthritis). 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. J Palliative Medicine 2002; 5; 73-84. Symptoms of heart failure or of the anginal syndrome may be present even at rest. 0000009368 00000 n Thus the overall rate of decline in each patient is fairly constant and predictable, unlike many other non-cancer diseases. Stage 3 (Early Confusional)Mild cognitive decline. <]/Prev 527120/XRefStm 1970>> ), Chronic Kidney Disease (1 and either 2, 3 or 4 should be present. Progression of disease as documented by worsening clinical status, symptoms, signs and laboratory results. They are listed in order of their likelihood to predict poor survival, the most predictive first and the least predictive last. Before sharing sensitive information, make sure you're on a federal government site. This page displays your requested Local Coverage Determination (LCD). Left ventricular hypertrophy or fibrosis; left ventricular dilatation or hypocontractility; asymptomatic valvular heart disease; previous myocardial infarction. 0000009983 00000 n The views and/or positions (Should fulfill 1, 2, or 3). They would use ICD-10-CM code E42 to report severe protein-calorie malnutrition with signs of both kwashiorkor and marasmus. If any physical activity is undertaken, discomfort is increased.) recipient email address(es) you enter. Patients who have developed structural heart disease that is strongly associated with the development of HF but who have never show signs or symptoms of HF. on this web site. E46 - Unspecified protein calorie malnutrition E64 - Sequelae of protein calorie malnutrition. Amyotrophic Lateral Sclerosis General Considerations: Criteria:Patients will be considered to be in the terminal stage of ALS (life expectancy of six months or less) if they meet the following criteria. 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. 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. This email will be sent from you to the THE UNITED STATES GOVERNMENT AND ITS EMPLOYEES ARE NOT LIABLE FOR ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN 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. 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. End User License Agreement: 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; recognition of familiar persons and faces; delusional behavior, e.g., patients may accuse their spouse of being an impostor, may talk to imaginary figures in the environment, or to their own reflection in the mirror; obsessive symptoms, e.g., person may continually repeat simple cleaning activities; anxiety agitation, and even previously nonexistent violent behavior may occur; cognitive abulia, i.e., loss of willpower because an individual cannot carry a thought long enough to determine a purposeful course of action. FAST scale. documentation. 0000037804 00000 n At the time of initial certification or recertification for hospice, the patient is or has been already optimally treated for heart disease or is not a candidate for a surgical procedure or has declined a procedure. 0000001970 00000 n 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. 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. 0000040363 00000 n 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. ): Increasing pCO2 or decreasing pO2 or decreasing SaO2; Increasing calcium, creatinine or liver function studies; Increasing tumor markers (e.g. While not necessarily a contraindication to Hospice care, the decision to institute either artificial ventilation or artificial feeding may significantly alter six month prognosis. 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). This Agreement will terminate upon notice if you violate its terms. National Government Services is not responsible for the continuing viability of Web site addresses listed below. Stage 4 (Late Confusional)Moderate cognitive decline. 0000008075 00000 n 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. Patients with dementia should show all the following characteristics: Patients should have had one of the following within the past 12 months: Note: This section is specific for Alzheimers Disease and related disorders, and is not appropriate for other types of dementia, such as multi-infarct dementia. Factors from 5 will lend supporting documentation.). 0000010879 00000 n Adult Malnutrition or Severe Protein Calorie Malnutrition PPS is < 40% Dependent for > 2 ADL's MI < 22 Weight loss (> 10% in 6 months, > 5% in 3 months) Hepatorenal syndrome Loss of muscle mass, subcutaneous fat Patient/family/DPOA wants hospice care and is refusing curative treatment Infections (aspiration pneumonia, urinary tract These are quite variable and include: Stage 7 (Late Dementia) Very severe cognitive decline. AHA copyrighted materials including the UB‐04 codes and Made a technical update to this LCD, to remove the empty Coding Information fields. J Palliative Medicine. 0000004710 00000 n 0000040080 00000 n 0000007316 00000 n End User Point and Click Amendment: The reviewer should be able to easily identify the dates and times of changes in levels of care and the reason for the change.In addition the documentation must comply with the requirements found in accordance with CMS IOM 100-02 Chapter 9 Section 20.Disease Specific GuidelinesNote: These guidelines are to be used in conjunction with the Non-disease specific baseline guidelines described in Part II of the basic policy.Section I: Cancer Diagnoses A. Significant congestive heart failure may be documented by an ejection fraction of less than or equal to 20%, but is not required if not already available. . All Rights Reserved. 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". Therefore, multiple clinical parameters are required to judge the progression of ALS. (1 and 2 should be present. 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. Hospice and primary care physicians: attitudes, knowledge, and barriers. In end-state ALS, two factors are critical in determining prognosis: ability to breathe, and to a lesser extent ability to swallow. The AMA does not directly or indirectly practice medicine or dispense medical services. 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. CPT is a trademark of the American Medical Association (AMA). 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. Denial begins to become manifest in patient. Copyright © 2022, the American Hospital Association, Chicago, Illinois. Applicable FARS/HHSARS apply. ALS tends to progress in a linear fashion over time. Marasmus, or PEM without edema, is . Any questions pertaining to the license or use of the CPT should be addressed to the AMA. Similarly, . such information, product, or processes will not infringe on privately owned rights. May have difficulty counting from 10, both backward and sometimes forward. For this reason, the history of the rate of progression in individual patients is important to obtain to predict prognosis. CDT is a trademark of the ADA. 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. 2000;320:469-472.Crooks V, Waller S, Smith T, Hahn TJ. (This value may be obtained from recent [within 3 months] hospital records.). 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. SERUM PROTEIN 0000017875 00000 n Inability to maintain sufficient fluid and calorie intake in past 6 months (10% weight loss or albumin <2.5) . ), 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. Generalized and cortical neurologic signs and symptoms are frequently present. Cancer. (1 and 2 should be present. Documentation of 3, 4, and 5, will lend supporting documentation. Inability to maintain hydration and caloric intake with 1 of the following: weight loss >10% in the last 6 months or >7. . The views and/or positions presented in the material do not necessarily represent the views of the AHA. If your session expires, you will lose all items in your basket and any active searches. It does not mean, however, that meeting the guideline is obligatory. LCD document IDs begin with the letter "L" (e.g., L12345). Muscle wasting with reduced strength and endurance; Continued active alcoholism (>80 gm ethanol/day); Hepatitis C refractory to interferon treatment. Before an LCD becomes final, the MAC publishes Proposed LCDs, which include a public comment period. The scope of this license is determined by the AMA, the copyright holder. Part III. Recurrent or intractable infections such as pneumonia, sepsis or upper urinary tract. Baseline data may be established on admission to hospice or by using existing information from records. 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. As used herein, "you" and "your" refer to you and any organization on behalf of which you are acting. (Class IV patients with heart disease have an inability to carry on any physical activity. The criteria refer to patients with various forms of advanced pulmonary disease who eventually follow a final common pathway for end stage pulmonary disease. Progression to dependence on assistance with additional activities of daily living (see Part II, Section 2). 0000040523 00000 n Other clinical variables not on this list may support a six-month or less life expectancy. Prognostic disclosure to patients with cancer near end of life. - Social Security Act, Sections 1102, 1812 (a)(4) and (d); 1813 (a) (4); 1814 (a)(7) and (I); 1862 (a)(1), (6), and (9); 1861 (dd), 1871- 42 CFR Part 418- CMS Publication 100-02, Medicare Benefit Policy, Chapter 9.- CMS Publication 100-04, Medicare Claims Processing, Chapter 30. Nutritional supplementation is one of the most important interventions in patients with failure to thrive. The patient is not seeking dialysis or renal transplant, or is discontinuing dialysis. ): 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. Some older versions have been archived. (1 and 2 should be present. Factors from 3 will add supporting documentation. 0000001587 00000 n It was developed in British Columbia, Canada. Circulation. Surface area of involvement of hemorrhage 30% of cerebrum; Obstructive hydrocephalus in patient who declines, or is not a candidate for, ventriculoperitoneal shunt. Subject to the terms and conditions contained in this Agreement, you, your employees and agents are authorized to use CDT only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. special, incidental, or consequential damages arising out of the use of such information, product, or process. First, make sure the malnutrition meets the definition of a secondary diagnosisi.e., is there evaluation, monitoring, treatment, increased nursing care and/or increased length of stay. An educated person may have difficulty counting back from 40 by 4s or from 20 by 2s. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. ): 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. Applicable Federal Acquisition Regulation Clauses (FARS)/Department of Defense Federal Acquisition Regulation supplement (DFARS) Restrictions Apply to Government Use. endstream endobj 660 0 obj <>stream AJ Hospice & Palliative Care. Please review and accept the agreements in order to view Medicare Coverage documents, which may include licensed information and codes. copied without the express written consent of the AHA. Barriers and enablers to hospice referrals: an expert overview. Baseline data may be established on admission to hospice or by using existing information from records. 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. 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. 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. Unable to ambulate without assistance. (1 and 2 should be present; factors from 3 will add supporting documentation. Progressive loss of abilities to walk, sit up, smile, and hold head up. 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. 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. 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. Part II. 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. Reproduced with permission. Normal activity with effort; some signs or symptoms of disease. Patients with advanced structural heart disease and marked symptoms of HF at rest despite maximal medical therapy and who require specialized interventions. ]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 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. 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. 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. J Clin Oncology. The AMA does not directly or indirectly practice medicine or dispense medical services. Pulmonary Disease. 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. Use of CDT is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). 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. Sign up to get the latest information about your choice of CMS topics in your inbox. CMS and its products and services are not endorsed by the AHA or any of its affiliates. Note that two of the disease specific guidelines (HIV Disease, Stroke and Coma) establish a lower qualifying KPS or PPS. (Optimally treated means that patients who are not on vasodilators have a medical reason for refusing these drugs, e.g., hypotension or renal disease.). 0000016419 00000 n These should be documented in the clinical record.These changes in clinical variables apply to patients whose decline is not considered to be reversible. In addition, an administrative law judge may not review an NCD. Almost always recall their own name. 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. Muscle wasting with reduced strength and endurance; Continued active alcoholism (> 80 gm ethanol/day); Hepatitis C refractory to interferon treatment. 0000039022 00000 n Intractable hyperkalemia (> 7.0) not responsive to treatment; Intractable fluid overload, not responsive to treatment. Unintentional progressive weight loss of greater than 10% of body weight over the preceding six months. Although guidelines applicable to certain disease categories are included, this policy is applicable to all hospice patients. These guidelines are to be used in conjunction with the Non-disease specific baseline guidelines described in Part II. An official website of the United States government. 0000002894 00000 n British Medical Journal 2000; 320; 469-472. West J Med. 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. All previously published UGS Local Medical Review Policies (LMRP)/Local Coverage Determinations (LCD).Medicare Contractor Medical Directors Hospice Workgroup. 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. Focusing on Protein-Calorie Malnutrition Protein-Calorie Malnutrition (PCM) The prevalence of protein-calorie malnutrition varies depending on the clinical setting. You can use your browser's Print function (Ctrl-P on a PC or Command-P on a Mac) to view a print preview and then select PDF as the output. Unable to dress without assistance. 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. not endorsed by the AHA or any of its affiliates. Progression of disease differs markedly from patient to patient. 2003;20: 41-51.Ogle K, Mavis B, Wang T. Physicians and hospice care: attitudes, knowledge and referrals. preparation of this material, or the analysis of information provided in the material. ALS tends to progress in a linear fashion over time. CPT codes, descriptions and other data only are copyright 2022 American Medical Association. 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. When performing a clinical validation review, start by confirming the presence of malnutrition and then apply validation to the level of severity. Use of CDT is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). 0000015606 00000 n 0000014923 00000 n The Global Malnutrition Composite Score (GMCS) electronic clinical quality measure is comprised of four components reflecting inpatient malnutrition identification and care. Experiences urinary and fecal incontinence. Frequently continue to be able to distinguish familiar from unfamiliar persons in their environment. CMS believes that the Internet is an effective method to share LCDs that Medicare contractors develop. or to place. 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. Factors from 5 will lend supporting documentation. 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 CDT is a trademark of the ADA. 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. However, no single variable deteriorates at a uniform rate in all patients. An asterisk (*) indicates a ), Patients 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. Lab testing is not required to establish hospice eligibility. 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. 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. Healthcare providers retain responsibility to submit complete and accurate. -*B Y81Ll8#\RRJvbbO:6c%^i4Ueuilos~8_i/qXlnv6L_KerIkEOL;v:5mMGzjqnfS)8UVy+YWyy~''vaOWpI.B'{0}|}|}|I,%%%%%%%%%%%%_^Az Extent and determinants of error in doctors prognoses in terminally ill patients: prospective cohort study. Sign up to get the latest information about your choice of CMS topics in your inbox. 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. 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.

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