such information, product, or processes will not infringe on privately owned rights. Patients with dementia or Alzheimer's are eligible for hospice care when they show all of the following characteristics: 1. Reproduced with permission. 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. 0000040523 00000 n Medicare contractors are required to develop and disseminate Local Coverage Determinations (LCDs). 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. Increasing emergency room visits, hospitalizations, or physicians visits related to hospice primary diagnosis, Progressive decline in Functional Assessment Staging (FAST) for dementia (from 7A on the FAST), Progression to dependence on assistance with additional activities of daily living (See Part II, Section 2), Progressive stage 3-4 pressure ulcers in spite of optimal care. Non-disease specific baseline guidelines (both A and B should be met), Part III. No fee schedules, basic unit, relative values or related listings are included in CPT. 0000039481 00000 n ), 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. @7Eq p[3gXsm!t;ON-:5,lX`9^n:myuT.sf~RG}|^no\x XP\w( The responsibility for the content of this file/product is with CMS and no endorsement by the AMA is intended or implied. 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. ), (1 and either 2 or 3 should be present. 0000012920 00000 n License to use CPT for any use not authorized herein must be obtained through the AMA, CPT Intellectual Property Services, AMA Plaza 330 N. Wabash Ave., Suite 39300, Chicago, IL 60611-5885. (1 and 2 should be present; factors from 3 will add supporting documentation. 0 These guidelines are to be used in conjunction with the Non-disease specific baseline guidelines described in Part II. However, no single variable deteriorates at a uniform rate in all patients. 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. License to use CPT for any use not authorized herein must be obtained through the AMA, CPT Intellectual Property Services, AMA Plaza 330 N. Wabash Ave., Suite 39300, Chicago, IL 60611-5885. Marasmus, or PEM without edema, is . "JavaScript" disabled. End User Point and Click Amendment: Creatinine clearance <10 cc/min (< 15 cc/min for diabetics); or < 15cc/min (< 20cc/min for diabetics) with comorbidity of congestive heart failure. 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. 0000005335 00000 n 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. 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. Applications are available at the American Dental Association web site. 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 authorized with an express license from the American Hospital Association. Instructions for enabling "JavaScript" can be found here. 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. (1 and 2 should be present. Applications are available at the AMA Web site, http://www.ama-assn.org/go/cpt. Dr Reisberg has also shown that the decline typical of Alzheimer's disease is the flip side of normal skill acquisition by infants, children, and young adults: Available from ElderCare Online http://www.ec-online.net/ Barry Reisberg, MD 1984. Co-morbidities. Significant congestive heart failure may be documented by an ejection fraction of 20%, but is not required if not already available. patients with slight, mild limitation of activity; they are comfortable with rest or with mild exertion. Coding professionals would use ICD-10-CM code E43 to report severe malnutrition, also known as starvation edema. 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. Also, you can decide how often you want to get updates. Coverage for these patients may be approved if documentation of clinical factors supporting a less than 6-month life expectancy not included in these guidelines is provided. ]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 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. 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. The patient is classified as New York Heart Association (NYHA) Class IV and may have significant symptoms of heart failure or angina at rest. (Documentation of serial decrease of FEV1>40 ml/year is objective evidence for disease progression, but is not necessary to obtain. Karnofsky Performance Status (KPS) or Palliative Performance Scale (PPS) of < 40% . MACs are Medicare contractors that develop LCDs and process Medicare claims. ): 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 or 3 should be present. Applicable FARS/HHSARS apply. Coverage Indications, Limitations, and/or Medical Necessity. It does not mean, however, that meeting the guideline is obligatory. RegVUA]rj N{ 8Qs. The records should include observations and data, not merely conclusions. 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. 7500 Security Boulevard, Baltimore, MD 21244. However, documentation expectations should comport with normal clinical documentation practices. 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. End User License Agreement: They require no assistance with toileting and eating, but may have some difficulty choosing the proper clothing to wear. Some patients may not meet these guidelines, yet still have a life expectancy of six months or less. 2003;20: 41-51.Ogle K, Mavis B, Wang T. Physicians and hospice care: attitudes, knowledge and referrals. Medicare program. DATE (05/31/2018): At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. 0000037087 00000 n 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. 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. 646 0 obj <> endobj 646 63 Examination by a neurologist within three months of assessment for hospice is advised, both to confirm the diagnosis and to assist with prognosis. CPT codes, descriptions and other data only are copyright 2022 American Medical Association. 2002;5:73-84.Hollen PJ, Gralla RJ, Dris MG, et al. CPT codes, descriptions and other data only are copyright 2022 American Medical Association. End Users do not act for or on behalf of the CMS. Patients 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: Patients at high risk of developing HF because of the presence of conditions that are strongly associated with the development of HF. Examination by a neurologist within three months of assessment for hospice is advised, both to confirm the diagnosis and to assist with prognosis. 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. recipient email address(es) you enter. 0000000016 00000 n xref 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. 0000032947 00000 n 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. on this web site. 1993;24:320- 327.Doyle D, Hanks G, Cherny N and Calman K. Oxford textbook of palliative medicine. 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. Inability to maintain sufficient fluid and calorie intake with 10% weight loss during the previous six months or serum albumin <2.5 gm/dl . Reproduced with permission. 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. 5 $q`$Hx OmR1ShJ6yehl~"YQiy8{ f P?9G5RW\t Generalized and cortical neurologic signs and symptoms are frequently present. for diabetics); or < 15cc/min (< 20cc/min for diabetics) with comorbidity of congestive heart failure. Personality and emotional changes occur. Moribund; fatal processes progressing rapidly. 0000017875 00000 n Learn more about the causes and symptoms. All rights reserved. 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. (This value may be obtained from recent [within 3 months] hospital records.). 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. 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. ), 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.) The 2023 edition of ICD-10-CM E43 became effective on October 1, 2022. Any questions pertaining to the license or use of the CPT should be addressed to the AMA. If your session expires, you will lose all items in your basket and any active searches. Decline in Karnofsky Performance Status (KPS ) or Palliative Performance Score (PPS) due to progression of disease. 0000007316 00000 n A patient will be considered to have a life expectancy of six months or less if he/she meets the non-disease specific. Stroke or coma. See Part III for disease specific guidelines to be used with these baseline guidelines. Accessed 01/16/2008.Schag CC, Heinrich RL, Ganz, PA. Karnofsky performance status revisited: Reliability, validity, and guidelines. Other clinical variables not on this list may support a six-month or less life expectancy. There has been no change in coverage with this LCD revision. Disease with distant metastases at presentation ORB. Pulmonary Disease. 0000016419 00000 n Some older versions have been archived. Also, you can decide how often you want to get updates. The Tracking Sheet modal can be closed and re-opened when viewing a Proposed LCD. 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. Requires assistance dressing, bathing, and toileting. The brain appears to no longer be able to tell the body what to do. Decline in Karnofsky Performance Status (KPS) or Palliative Performance Score (PPS) from <70% due to progression of disease. Life-threatening complications as demonstrated by one of the following characteristics occurring within the 12 months preceding initial hospice certification: Recurrent aspiration pneumonia (with or without tube feedings); Upper urinary tract infection, e.g., pyelonephritis; Recurrent fever after antibiotic therapy; Stage seven or beyond according to the Functional Assessment Staging Scale. 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. Any questions pertaining to the license or use of the CPT should be addressed to the AMA. Consistent with Change Request 10901, all coding information, National coverage provisions, and Associated Information (Documentation Requirements, Utilization Guidelines) have been removed from the LCD and placed in the related Billing and Coding Article, A52830. All rights reserved. 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. 1999;22(6):385-90.Lamont E, Christakis N. Prognostic disclosure to patients with cancer near the end of life. Systemic hypertension; coronary artery disease; diabetes mellitus; history of cardiotoxic drug therapy or alcohol abuse; personal history of rheumatic fever; family history of cardiomyopathy. . 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. While these characteristics are assessed along a continuum, rather than as discrete variables, they are useful in formulating and documenting a diagnosis of malnutrition. Secondary Criteria Notes . 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. But specific entries can also call for an answer, such as an opinion by one team member or recovery of ADLS when they were part of the basis for the initial declaration of eligibility. (Class IV patients with heart disease have an inability to carry on any physical activity. recommending their use. 0000004710 00000 n 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. Patient declines further disease directed therapy. Copyright © 2022, the American Hospital Association, Chicago, Illinois. Patients with congestive heart failure or angina should meet the criteria for the New York Heart Association (NYHA) Class IV. 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. This page displays your requested Local Coverage Determination (LCD). N. Christakis, E. Lamont. Protein Calorie Malnutrition Hospice Criteria. As used herein, "you" and "your" refer to you and any organization on behalf of which you are acting. ), 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. As with any other condition, an individual with renal disease is eligible for the Hospice benefit if that individual has a prognosis of six months or less, if the illness runs its normal course. Hospice Eligibility Criteria Patient has a terminal illness with a life . 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. Unable to work; able to live at home and care for most personal needs; varying amount of assistance needed.