At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. For this reason, the history of the rate of progression in individual patients is important to obtain to predict prognosis. The criteria refer to patients with various forms of advanced pulmonary disease who eventually follow a final common pathway for end stage pulmonary disease. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or Made a technical update to this LCD, to remove the empty Coding Information fields. Able to carry on normal activity; minor signs or symptoms of disease. 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. 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. Factors from 3 will add supporting documentation. 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. Neither the United States Government nor its employees represent that use of Physiologic impairment of functional status as demonstrated by: Karnofsky Performance Status (KPS) or Palliative Performance Score (PPS) < 70%. Although guidelines applicable to certain disease categories are included, this policy is applicable to all hospice patients. Revision Explanation:Converted policy into new policy template that no longer includes coding section based on CR 10901. recipient email address(es) you enter. If you would like to extend your session, you may select the Continue Button. 0000004710 00000 n Manifestations in more than one of the following areas: Objective evidence of memory deficit obtained only with an intensive interview. Examination by a neurologist within three months of assessment for hospice is advised, both to confirm the diagnosis and to assist with prognosis. 0000037955 00000 n Revision Explanation: Annual review no changes were made. 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. Circulation. 1984;2:187-193. Sign up to get the latest information about your choice of CMS topics in your inbox. This email will be sent from you to the 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). "JavaScript" disabled. LCDs outline how the contractor will review claims to ensure that the services provided meet Medicare coverage requirements. Medicare program. 7500 Security Boulevard, Baltimore, MD 21244. Systemic hypertension; coronary artery disease; diabetes mellitus; history of cardiotoxic drug therapy or alcohol abuse; personal history of rheumatic fever; family history of cardiomyopathy. 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. Stage2 (Forgetfulness)Very mild cognitive decline. All rights reserved. The score can help determine which patients can be managed in the home and which should be admitted to a hospice unit. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816. 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. 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. LCD document IDs begin with the letter "L" (e.g., L12345). ): 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. Baseline data may be established on admission to hospice or by using existing information from records. Alzheimer's disease and other progressive dementias are life-altering and eventually fatal conditions for which curative therapy is not available. 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 former can be managed by artificial ventilation, and the latter by gastrostomy or other artificial feeding, unless the patient has recurrent aspiration pneumonia. presented in the material do not necessarily represent the views of the AHA. 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. Flattening of affect and withdrawal from challenging situations occur. Patient should demonstrate critically impaired breathing capacity. 2003;20: 41-51.Ogle K, Mavis B, Wang T. Physicians and hospice care: attitudes, knowledge and referrals. Although guidelines applicable to certain disease categories are included, this LCD is applicable to all hospice patients. not endorsed by the AHA or any of its affiliates. 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. 0000013372 00000 n ALS tends to progress in a linear fashion over time. This can be used to compare effectiveness of different therapies and to assess the prognosis in individual patients. Incontinent of urine, requires assistance toileting and feeding. If other clinical indicators of decline not listed in this policy such as psychological and spiritual factors form the basis for certifying terminal status, they should be documented as well. ), 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. Reproduced with permission. The criteria refer to patients with various forms of advanced pulmonary disease who eventually follow a final common pathway for end stage pulmonary disease. startxref 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. 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. If a patient improves 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. Ogle K, Mavis B, Wang T. Hospice and primary care physicians: attitudes, knowledge, and barriers. ; Obstructive hydrocephalus in patient who declines, or is not a candidate for, ventriculoperitoneal shunt. Right heart failure (RHF) secondary to pulmonary disease (Cor pulmonale) (e.g., not secondary to left heart disease or valvulopathy). Factors from 5 will lend supporting documentation.). 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. An official website of the United States government. 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. 0000029167 00000 n "JavaScript" disabled. An asterisk (*) indicates a 0000022017 00000 n Laboratory tests in protein-calorie malnutrition Lancet. Such patients have no identified structural or functional abnormalities of the pericardium, myocardium, or cardiac valves and have never shown signs or symptoms of HF.Example:Systemic hypertension; coronary artery disease; diabetes mellitus; history of cardiotoxic drug therapy or alcohol abuse; personal history of rheumatic fever; family history of cardiomyopathy.Stage BPatients 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.Example:Left ventricular hypertrophy or fibrosis; left ventricular dilatation or hypocontractility; asymptomatic valvular heart disease; previous myocardial infarction.Stage CPatients who have current or prior symptoms of HF associated with underlying structural heart disease.Example:Dyspnea or fatigue due to left ventricular systolic dysfunction; asymptomatic patients who are undergoing treatment for prior symptoms of HF.Stage DPatients with advanced structural heart disease and marked symptoms of HF at rest despite maximal medical therapy and who require specialized interventions.Example:Patients who are frequently hospitalized for HF or cannot be safely discharged from the hospital; patients in the hospital awaiting heart transplantation; patients at home receiving continuous intravenous support for symptom relief or being supported with a mechanical circulatory assist device; patients in a hospice setting for management of HF.Karnofsky Performance Scale (KPS)The Karnofsky Performance Scale Index allows patients to be classified as to their functional impairment. The AMA is a third party beneficiary to this Agreement. Patients who are frequently hospitalized for HF or cannot be safely discharged from the hospital; patients in the hospital awaiting heart transplantation; patients at home receiving continuous intravenous support for symptom relief or being supported with a mechanical circulatory assist device; patients in a hospice setting for management of HF. 0000008839 00000 n 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. No objective deficits in employment or social situations. 0000003355 00000 n Revision Explanation: Annual review no changes made. The 2023 edition of ICD-10-CM E46 became effective on October 1, 2022. CDT is a trademark of the ADA. 0000038553 00000 n Made a technical update to this LCD to remove the empty Coding Information fields. 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. "JavaScript" disabled. Diurnal rhythm frequently disturbed. Progressive decline in Functional Assessment Staging (FAST) for dementia (from 7A on the FAST). AHA copyrighted materials including the UB‐04 codes and Applications are available at the AMA Web site, http://www.ama-assn.org/go/cpt. 1993:109.Friedman B, Harwood S. Barriers and enablers to hospice referrals: an expert overview. endstream endobj 660 0 obj <>stream The AMA does not directly or indirectly practice medicine or dispense medical services. Current Dental Terminology © 2022 American Dental Association. CPT is a trademark of the American Medical Association (AMA). (1 and 2 should be present, factors from 3 will lend supporting documentation. 0000009368 00000 n THE UNITED STATES GOVERNMENT AND ITS EMPLOYEES ARE NOT LIABLE FOR ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN All rights reserved.

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