At least two of the six characteristics are needed for the diagnosis of malnutrition. Clinical variables with general applicability without regard to diagnosis, as well as clinical variables applicable to a limited number of specific diagnoses, are provided. without the written consent of the AHA. Federal government websites often end in .gov or .mil. 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. You are leaving the CMS MCD and are being redirected to the CMS MCD Archive that contains outdated (No Longer In Effect) Local Coverage Determinations and Articles, You are leaving the CMS MCD and are being redirected to, For services performed on or after 10/01/2015, For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. 0000025584 00000 n Requires assistance dressing, bathing, and toileting. These should be documented in the clinical record.These changes in clinical variables apply to patients whose decline is not considered to be reversible. Stage 6 (Middle Dementia) Severe cognitive decline.May occasionally forget the name of the spouse upon whom they are entirely dependent for survival. Made a technical update to this LCD to remove the empty Coding Information fields. Frequently some disorientation to time (date, day of week, season, etc.) 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. Right heart failure (RHF) secondary to pulmonary disease (Cor pulmonale) (e.g., not secondary to left heart disease or valvulopathy). Annals of Internal Medicine. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT. 0000000016 00000 n Severity of malnutrition is based on phenotypic criteria only and requires one phenotypic criterion that meets the threshold of . This bibliography presents those sources that were obtained during the development of this policy. copied without the express written consent of the AHA. 0000061858 00000 n 2004;7(1):47-53. 646 63 (1 and 2 should be present. 1993;24:320- 327.Doyle D, Hanks G, Cherny N and Calman K. Oxford textbook of palliative medicine. B. 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. Proposed LCD document IDs begin with the letters "DL" (e.g., DL12345). Frequently there is no speech at all - only grunting. The population for key question 3 will only include patients with a diagnosis of protein-energy malnutrition. Requires occasional assistance, but is able to care for most of his personal needs. ), 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. 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. 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). Factors from 3 will add supporting documentation. J Palliative Medicine. 0000038995 00000 n The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or While not necessarily a contraindication to Hospice care, the decision to institute either artificial ventilation or artificial feeding may significantly alter six month prognosis. Sign up to get the latest information about your choice of CMS topics in your inbox. Please note that codes (CPT/HCPCS and ICD-10) have moved from LCDs to Billing & Coding Articles. CMS and its products and services are 0000008839 00000 n 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. 0000011336 00000 n Requires considerable assistance and frequent medical care. Dyspnea with increasing respiratory rate; Nausea/vomiting poorly responsive to treatment; Pain requiring increasing doses of major analgesics more than briefly. Medicare contractors are required to develop and disseminate Local Coverage Determinations (LCDs). Some patients may not meet these guidelines, yet still have a life expectancy of six months or less. LCD document IDs begin with the letter "L" (e.g., L12345). Revision Explanation: Annual review no changes were made. Skip to main content Skip to navigation Skip to navigation. Appropriate concern regarding symptoms. Some older versions have been archived. The use of the New York heart association's classification of cardiovascular disease as part of the patient's complete problem list. ), 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. 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. The FAST scale has 16 stages and sub-stages: Personal awareness of some functional decline. OR Hypercapnia, as evidenced by pCO2 50 mmHg. ), 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.) Incontinent of urine, requires assistance toileting and feeding. 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. 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. sensitive to and specic for protein-calorie malnutrition.4 Serum hepatic protein levels help the clinician to identify the sickest of patientsthose who may be more likely to develop malnutrition.1 It is imperative that the registered dietitian nutritionist in-terprets hepatic protein levels in the context of the patient's overall health While these characteristics are assessed along a continuum, rather than as discrete variables, they are useful in formulating and documenting a diagnosis of malnutrition. 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. Laboratory tests in protein-calorie malnutrition. Mild to moderate anxiety accompanies symptoms. The score can help determine which patients can be managed in the home and which should be admitted to a hospice unit. Golden, AM. CMS and its products and services are 0000038553 00000 n PCM is estimated at 4% in the community setting; 29% in sub-acute care facilities; 27% and 38% among the hospitalized elderly aged 60 - 79 and aged 80 and older, respectively; and . special, incidental, or consequential damages arising out of the use of such information, product, or process. 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. Use of CDT is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). 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. H\n0)B-FZBo>9X;frYQkh!:?^rt:wn/6]rO7go7c?[\zVi/6K]9bKCO1r{O=fU%=Xfey.)2"/g6_n. If any physical activity is undertaken, discomfort is increased.) Patient should demonstrate both rapid progression of ALS and life-threatening complications. Factors from 4 will lend supporting documentation. 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. Lose basic psychomotor skills, e.g., ability to walk, sitting and head control. 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. You can use the Contents side panel to help navigate the various sections. 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. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be Cares for self; unable to carry on normal activity or to do active work. Please enable "JavaScript" and revisit this page or proceed with browsing CMS.gov with and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only 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. Protein calorie malnutrition, nutritional intervention and personalized cancer care Authors Anju Gangadharan 1 , Sung Eun Choi 2 , Ahmed Hassan 1 , Nehad M Ayoub 3 , Gina Durante 4 , Sakshi Balwani 1 , Young Hee Kim 4 , Andrew Pecora 5 , Andre Goy 5 , K Stephen Suh 1 Affiliations 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". 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. While it is true that there is not a strict six month limit on the Hospice benefit, the underlying precept is that the beneficiary must have a prognosis of six months or less, if the illness runs its normal course. Neither the United States Government nor its employees represent that use of Patients will be considered to be in the terminal stage of dementia (life expectancy of six months or less) if they meet the following criteria. Physiologic impairment of functional status as demonstrated by: Dependence on assistance for two or more activities of daily living (ADLs), Neurologic disease (CVA, ALS, MS, Parkinsons). Estimated glomerular filtration rate (GFR) <10 ml/min. Unable to ambulate without assistance. Denial is dominant defense mechanism. recommending their use. 1984;2:187-193. Frequently no deficit in the following areas: Inability to perform complex tasks. Cancer. 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. 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. Stroke. 1973 May 12;1(7811):1041-2. Although guidelines applicable to certain disease categories are included, this LCD is applicable to all hospice patients. http://www.ed-online.net\. Coverage for these patients may be approved if documentation otherwise supporting a less than six-month life expectancy is provided.Section 322 of BIPA amended section 1814(a) of the Social Security Act by clarifying that the certification of an individual who elects hospice "shall be based on the physician's or medical director's clinical judgment regarding the normal course of the individual's illness.'' Reproduced with permission. 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). Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, Patient declines further disease directed therapy. Intractable hyperkalemia (> 7.0) not responsive to treatment; Intractable fluid overload, not responsive to treatment. 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. A: Determining when to query for a malnutrition diagnosis can be very tricky. descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work All rights reserved. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or They are examples of findings that generally connote a poor prognosis. ), 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. (Documentation of serial decrease of FEV1>40 ml/year is objective evidence for disease progression, but is not necessary to obtain. 0000003355 00000 n In end-state ALS, two factors are critical in determining prognosis: ability to breathe, and to a lesser extent ability to swallow. (Class IV patients with heart disease have an inability to carry on any physical activity without discomfort. accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the 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 Baseline data may be established on admission to hospice or by using existing information from records. ), 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. All verbal abilities are lost. This section is specific for Alzheimers disease and Related Disorders, and is not appropriate for other types of dementia. There are multiple ways to create a PDF of a document that you are currently viewing. Factors from 5 will lend supporting documentation. National Government Services is not responsible for the continuing viability of Web site addresses listed below. These guidelines are to be used in conjunction with the Non-disease specific baseline guidelines described in Part II. CPT codes, descriptions and other data only are copyright 2022 American Medical Association. Non-disease specific baseline guidelines (both A and B should be met), Part III. Subjective complaints of memory deficit, most frequently in the following area: No objective evidence of memory deficit on clinical interview. Although ALS usually presents in a localized anatomical area, the location of initial presentation does not correlate with survival time. ): Increasing pCO2 or decreasing pO2 or decreasing SaO2; Increasing calcium, creatinine or liver function studies; Increasing tumor markers (e.g. 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. The Centers for Medicare & Medicaid Services (CMS), the federal agency responsible for administration of the Medicare, Medicaid 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. All rights reserved. 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). 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. Stage 1No cognitive decline. 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. Many patients exhibit symptoms of both disease states. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. and the State Children's Health Insurance Programs, contracts with certain organizations to assist in the administration of the 0000013372 00000 n Please visit the, Progression of disease as documented by worsening clinical status, symptoms, signs and laboratory results. (1 and 2 should be present, factors from 3 will lend supporting documentation. This can be used to compare effectiveness of different therapies and to assess the prognosis in individual patients. authorized with an express license from the American Hospital Association. Stage2 (Forgetfulness)Very mild cognitive decline. RegVUA]rj N{ 8Qs. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials. 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. Before sharing sensitive information, make sure you're on a federal government site. startxref 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. There has been no change in coverage with this LCD revision. Surface area of involvement of hemorrhage 30% of cerebrum; Obstructive hydrocephalus in patient who declines, or is not a candidate for, ventriculoperitoneal shunt. Please note that if you choose to continue without enabling "JavaScript" certain functionalities on this website may not be available. To capture use of hypocaloric PN dosing. The AMA does not directly or indirectly practice medicine or dispense medical services. MACs are Medicare contractors that develop LCDs and process Medicare claims. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. hbbRc`b``3 1x4>.0 Thus a patient with metastatic small cell CA may be demonstrated to be hospice eligible with less documentation than a chronic lung disease patient. They are examples of findings that generally connote a poor prognosis. 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). Current Dental Terminology © 2022 American Dental Association. E40 refers to Kwashiorkor is severe malnutrition with nutritional edema and dyspigmentation of skin and hair. Despite the prevalence of protein-calorie malnutrition (PCM) in acute-care hospitals and long-term care centers, a national and global consensus on nutrition screening and malnutrition diagnosis is lacking. on this web site. Some patients decline rapidly and die quickly; others progress more slowly. Unintentional progressive weight loss of greater than 10% of body weight over the preceding six months. Before an LCD becomes final, the MAC publishes Proposed LCDs, which include a public comment period. 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. They may be incorporated by specific reference as part (or all) of the indication for recertification. t'h0&@,41%;j4aJEG>wJ4RA0^c 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. ), Increasing pCO2 or decreasing pO2 or decreasing SaO2, Increasing calcium, creatinine or liver function studies, Progressively decreasing or increasing serum sodium or increasing serum potassium. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816. While every effort has Abnormal brain stem response 1993:109.Friedman B, Harwood S. Barriers and enablers to hospice referrals: an expert overview. The criteria refer to patients with various forms of advanced pulmonary disease who eventually follow a final common pathway for end stage pulmonary disease. Undernutrition happens when you don't consume enough essential nutrients, or when you use/excrete the nutrients faster than they are replaced (1). Protein and calorie deficiencies alter insulin, growth hormone and cortisol levels, curtail hepatic function, and deplete mineral stores. E46 - Unspecified protein calorie malnutrition E64 - Sequelae of protein calorie malnutrition. 0000040550 00000 n malnutrition (263.0: Malnutrition of a Moderate Degree) and severe malnutrition (262: Other Severe Protein Calorie Malnutrition). 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. 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; CPT codes, descriptions and other data only are copyright 2022 American Medical Association. 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. + Note that two of the disease specific guidelines (HIV Disease, Stroke and Coma) establish a lower qualifying KPS or PPS. AJ Hospice & Palliative Care, 2003; 20; 41-51. 0000159154 00000 n 3p=3t8@g3`PWYGQGYGQGYGQGYGQGo_e~kWB[({W}cw}QnoooooERa^*H78mQ_/.K 0 This Agreement will terminate upon notice if you violate its terms. The AMA does not directly or indirectly practice medicine or dispense medical services. These should be documented in the clinical record.These changes in clinical variables apply to patients whose decline is not considered to be reversible. (Documentation of serial decrease of FEV1>40 ml/year is objective evidence for disease progression, but is not necessary to obtain. Normal no complaints; no evidence of disease. British Medical Journal. As each patient is unique, there are patients for whom a particular guideline does not match. Proposed LCD document IDs begin with the letters "DL" (e.g., DL12345). or to place. <]/Prev 527120/XRefStm 1970>> recipient email address(es) you enter. Recertification for hospice care requires the same clinical standards be met as for initial certification, but they need not be reiterated. 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.IndicationsA patient will be considered to have a life expectancy of six months or less if he/she meets the non-disease specific "Decline in clinical status" guidelines described in Part I. Alternatively, the baseline non-disease specific guidelines described in Part II plus the applicable disease specific guidelines listed in Part III will establish the necessary expectancy.Part I. patients with marked limitation of activity; they are comfortable only at rest. The criteria refer to patients with various forms of advanced pulmonary disease who eventually follow a final common pathway for end stage pulmonary disease. LCDs outline how the contractor will review claims to ensure that the services provided meet Medicare coverage requirements. In end-state ALS, two factors are critical in determining prognosis: ability to breathe, and to a lesser extent ability to swallow. Symptoms Include a number of symptoms, including nausea and vomiting, dyspnea, persisting cough, fatigue, decreased cognition, diarrhea, and progressive pain Signs Unable to dress without assistance. 0000017107 00000 n Coverage Indications, Limitations, and/or Medical Necessity. Almost always recall their own name. 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 UNITED STATES GOVERNMENT AND ITS EMPLOYEES ARE NOT LIABLE FOR ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN This page displays your requested Local Coverage Determination (LCD).