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. )ndgM`.K3{daYpz:=~F~c~Cm& m& m& m& m#=#)XOz The 2023 edition of ICD-10-CM E43 became effective on October 1, 2022. 1984;2:187-193. It places patients in one of four categories, based on how much they are limited during physical activity:Class I: patients with no limitation of activities; they suffer no symptoms from ordinary activities.Class II: patients with slight, mild limitation of activity; they are comfortable with rest or with mild exertion.Class III: patients with marked limitation of activity; they are comfortable only at rest.Class IV: patients who should be at complete rest, confined to bed or chair; any physical activity brings on discomfort and symptoms occur at rest.Palliative Performance ScaleThe Palliative Performance Scale (PPS) is a modification of the Karnofsky Performance Scale intended for evaluating patients requiring palliative care. Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, 0000040523 00000 n 2000;320:469-472.Crooks V, Waller S, Smith T, Hahn TJ. 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. The 2023 edition of ICD-10-CM E46 became effective on October 1, 2022. Inability to maintain hydration and caloric intake with 1 of the following: weight loss >10% in the last 6 months or >7. . Creatinine clearance < 10 cc/min (<15 cc/min. routine or continuous home or inpatient, respite, or general. NYHA Functional Classification for Congestive Heart FailureThe New York Heart Association (NYHA) Functional Classification provides a simple way of classifying heart disease (originally cardiac failure). Protein Calorie Malnutrition Severe Protein Calorie Malnutrition Moderate Protein Calorie Malnutrition Severe Protein Calorie Malnutrition Energy Intake <75% of EEE >7 days 50 % of EEE >5 days <75% of EEE 1 month <75% of EEE 1 month <75% of EEE 3 months 50% of EEE 1 month Weight Loss not endorsed by the AHA or any of its affiliates. CMS and its products and services are not endorsed by the AHA or any of its affiliates. It does not mean, however, that meeting the guideline is obligatory. 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. Stroke. Diurnal rhythm frequently disturbed. 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. > Measurement of quality of life in patients with lung cancer in multicenter trials of new therapies. There has been no change in coverage with this LCD revision. Proposed LCD document IDs begin with the letters "DL" (e.g., DL12345). 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. Critical nutritional impairment as demonstrated by all the following characteristics occurring within the 12 months preceding initial hospice certification: Oral intake of nutrients and fluids insufficient to sustain life; Absence of artificial feeding methods, sufficient to sustain life, but not for relieving hunger. Coma Primary Criteria Patient with any 3 of the following on day three of coma: 1. All previously published UGS Local Medical Review Policies (LMRP)/Local Coverage Determinations (LCD).Medicare Contractor Medical Directors Hospice Workgroup. Factors from 4 will lend supporting documentation. ), Pulmonary DiseasePatients 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. (1 and 2 should be present. xref Applications are available at the AMA Web site, http://www.ama-assn.org/go/cpt. 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. 708 0 obj <>stream 0000004098 00000 n Documentation of the following factors will support but is not required to establish eligibility for hospice care: Treatment resistant symptomatic supraventricular or ventricular arrhythmias; History of cardiac arrest or resuscitation; CD4+ Count 100,000 copies/ml, plus one of the following: Untreated, or persistent despite treatment, wasting (loss of at least 10% lean body mass); Mycobacterium avium complex (MAC) bacteremia, untreated, unresponsive to treatment, or treatment refused; Progressive multifocal leukoencephalopathy; Systemic lymphoma, with advanced HIV disease and partial response to chemotherapy; Visceral Kaposis sarcoma unresponsive to therapy; Renal failure in the absence of dialysis; Decreased performance status, as measured by the Karnofsky Performance Status (KPS) scale, of 50%. This can be used to compare effectiveness of different therapies and to assess the prognosis in individual patients. There are multiple ways to create a PDF of a document that you are currently viewing. Non-disease specific baseline guidelines (both A and B should be met), Part III. Flattening of affect and withdrawal from challenging situations occur. 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. While these characteristics are assessed along a continuum, rather than as discrete variables, they are useful in formulating and documenting a diagnosis of malnutrition. While every effort has 0000038836 00000 n Clinical variables with general applicability without regard to diagnosis, as well as clinical variables applicable to a limited number of specific diagnoses, are provided. 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. Unspecified protein-calorie malnutrition. A52830 - Billing and Coding: Hospice: Determining Terminal Status. LCD document IDs begin with the letter "L" (e.g., L12345). Percentage of patients receiving PN in the ICU who receive 80% of estimated energy requirements or 20 kcals/kg/day and a minimum of 1.2 g protein/kg/day. The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. 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. 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. This policy describes guidelines to be used by Home Health & Hospice (HH&H) MAC in reviewing hospice claims and by hospice providers to determine eligibility of beneficiaries for hospice benefits. Baker D, Chin M, Cinquigrani M, et al. 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. Progressive decline in Functional Assessment Staging (FAST) for dementia (from 7A on the FAST). 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. Therefore, multiple clinical parameters are required to judge the progression of ALS. All Rights Reserved (or such other date of publication of CPT). In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material. At least two of the six characteristics are needed for the diagnosis of malnutrition. As used herein, "you" and "your" refer to you and any organization on behalf of which you are acting. 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 No objective deficits in employment or social situations. Part II. 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 CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. R7Revision Effective: 01/21/2021Revision Explanation: Updated values to the liver and renal disease section based on KDIGO information in the general associated information section and corrected formatting were needed. Speech ability declines to about a half-dozen intelligible words. 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. ge"^WOgr |___W+ tpIht=hozGC8 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. H\n0)B-FZBo>9X;frYQkh!:?^rt:wn/6]rO7go7c?[\zVi/6K]9bKCO1r{O=fU%=Xfey.)2"/g6_n. 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. Lab testing is not required to establish hospice eligibility. without the written consent of the AHA. The Global Malnutrition Composite Score (GMCS) electronic clinical quality measure is comprised of four components reflecting inpatient malnutrition identification and care. 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. 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. Some patients decline rapidly and die quickly; others progress more slowly. When performing a clinical validation review, start by confirming the presence of malnutrition and then apply validation to the level of severity. OR Hypercapnia, as evidenced by pCO2 50 mmHg. 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. Oxford University Press. The views and/or positions presented in the material do not necessarily represent the views of the AHA. These materials contain Current Dental Terminology (CDTTM), copyright© 2022 American Dental Association (ADA). The patient is not seeking dialysis or renal transplant, or is discontinuing dialysis; 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. Applications are available at the American Dental Association web site. Patients with dementia or Alzheimer's are eligible for hospice care when they show all of the following characteristics: 1. Recertification for hospice care requires the same clinical standards be met as for initial certification, but they need not be reiterated. If your session expires, you will lose all items in your basket and any active searches. 7500 Security Boulevard, Baltimore, MD 21244. Progression from an earlier stage of disease to metastatic disease with either:1. a continued decline in spite of therapy2. 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. decreased knowledge of current and recent events; may exhibit some deficit in memory of one's personal history; concentration deficit elicited on serial subtractions; decreased ability to travel, handle finances, etc. J Gerontol. 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. endstream endobj 659 0 obj <>stream You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.