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Please note that codes (CPT/HCPCS and ICD-10) have moved from LCDs to Billing & Coding Articles. MACs are Medicare contractors that develop LCDs and process Medicare claims. endstream endobj 657 0 obj <> endobj 658 0 obj <>stream 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. Progression from an earlier stage of disease to metastatic disease with either:1. a continued decline in spite of therapy2. Geriatric Failure to Thrive | AAFP 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. R8Revision Effective: 05/06/2021Revision Explanation: Corrected typo in the associated information section under acute renal failure. Documentation of 3, 4, and 5, will lend supporting documentation.). Although guidelines applicable to certain disease categories are included, this LCD is applicable to all hospice patients. Karnofsky Performance Status (KPS) or Palliative Performance Scale (PPS) of < 40% . 0000014780 00000 n . Use is limited to use in Medicare, Medicaid or other programs administered by the Centers for Medicare and Medicaid Services (CMS). This page displays your requested Local Coverage Determination (LCD). 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. 0000039022 00000 n 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. End User Point and Click Amendment: While every effort has J Palliative Medicine. The responsibility for the content of this file/product is with CMS and no endorsement by the AMA is intended or implied. Instructions for enabling "JavaScript" can be found here. Almost always recall their own name. 2000;320:469-472.Crooks V, Waller S, Smith T, Hahn TJ. 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. SPECIFIC INDICATIONS:A 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 the appendix will establish the necessary expectancy. It is rare occurrence in the U.S. E41 is used to report nutritional marasmus, a form of malnutrition characterized by consumption of . They invariably know their own names and generally know their spouse's and children's names. required field. 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. All Rights Reserved. Earliest clear-cut deficits. Mild protein-calorie malnutrition (weight for age 75-89% of standard) Protein calorie malnutrition, mild (gomez 75-90% s ICD-10-CM E44.1 is grouped within Diagnostic Related Group (s) (MS-DRG v40.0): 640 Miscellaneous disorders of nutrition, metabolism, fluids and electrolytes with mcc J Palliative Medicine 2002; 5; 73-84. 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. Requires assistance in choosing proper attire. Unless elements in the record require explanation, such as a non-morbid diagnosis or indicators of likely greater than 6-month survival, as stated below, no extra or additional record entries should be needed to show hospice benefit eligibility.The amount and detail of documentation will differ in different situations. HUjI}iuU!v` "Y]I!T 3:NU^#={6: K]Sdl*B!XA-m2{gcm8n W)' fvtkW~e,y&2%!98kzb . Revision Explanation: Annual review, no changes made. GENERAL INDICATIONS: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. Medicare program. Pulmonary Disease. 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. You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement. 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. Cancer. Denial begins to become manifest in patient. Applications are available at the American Dental Association web site. Learn more about the causes and symptoms. 0000038836 00000 n Rapid progression of ALS as demonstrated by all the following characteristics occurring within the 12 months preceding initial hospice certification: Progression from independent ambulation to wheelchair to bed bound status; Progression from normal to barely intelligible or unintelligible speech; Progression from independence in most or all activities of daily living (ADLs) to needing major assistance by caretaker in all ADLs. If any physical activity is undertaken, discomfort is increased.) It was developed in British Columbia, Canada. "JavaScript" disabled. This LCD outlines coverage for hospice as indicated in the coverage and indications section. E. Lamont, N. Christakis. 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. 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. The patient is classified as New York Heart Association (NYHA) Class IV and may have significant symptoms of heart failure or angina at rest. "JavaScript" disabled. + Revision Explanation: Annual review no changes made. 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). 1991;155:384-387.Reisberg B. ElderCare online. SERUM PROTEIN Factors from 5 will lend supporting documentation. endstream endobj 659 0 obj <>stream You can use the Contents side panel to help navigate the various sections. British Medical Journal. 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. 0000008630 00000 n The AMA assumes no liability for data contained or not contained herein. 0000029167 00000 n Although ALS usually presents in a localized anatomical area, the location of initial presentation does not correlate with survival time. documentation. The LCD Tracking Sheet is a pop-up modal that is displayed on top of any Proposed LCD that began to appear on the MCD on or after 1/1/2022. H\n0)B-FZBo>9X;frYQkh!:?^rt:wn/6]rO7go7c?[\zVi/6K]9bKCO1r{O=fU%=Xfey.)2"/g6_n. These are quite variable and include: Stage 7 (Late Dementia) Very severe cognitive decline. ]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 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. There has been no change in coverage with this LCD revision. patients who should be at complete rest, confined to bed or chair; any physical activity brings on discomfort and symptoms occur at rest. startxref 0000008742 00000 n 0000004710 00000 n 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. Applications are available at the American Dental Association web site. (1 and 2 should be present. Unspecified severe protein-calorie malnutrition. Alzheimer's disease and other progressive dementias are life-altering and eventually fatal conditions for which curative therapy is not available. May have difficulty counting from 10, both backward and sometimes forward. Retain some knowledge of their past lives but this is very sketchy. (1 and 2 should be present; factors from 3 will add supporting documentation. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be ge"^WOgr |___W+ tpIht=hozGC8 Frequently some disorientation to time (date, day of week, season, etc.) The scope of this license is determined by the AMA, the copyright holder. Systemic hypertension; coronary artery disease; diabetes mellitus; history of cardiotoxic drug therapy or alcohol abuse; personal history of rheumatic fever; family history of cardiomyopathy. Annals of Internal Medicine 2001; 134; 1097-1143. Unable to work; able to live at home and care for most personal needs; varying amount of assistance needed. If any physical activity is undertaken, discomfort is increased.) The use of the Karnofsky Performance Scale in determining outcomes and risk in geriatric outpatients. Decline in clinical status guidelines 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. The AMA is a third party beneficiary to this Agreement. 2001;104:2996-3007. 0000010879 00000 n PDF Protein-calorie malnutrition - bcidaho.com Baseline data may be established on admission to hospice or by using existing information from records. R2Revision Effective: N/ARevision Explanation: Annual review no changes made. Creatinine clearance <10 cc/min (< 15 cc/min for diabetics); or < 15cc/min (< 20cc/min for diabetics) with comorbidity of congestive heart failure. Made a technical update to this LCD to remove the empty Coding Information fields. If you do not agree with all terms and conditions set forth herein, click below on the button labeled "I do not accept" and exit from this computer screen. ), 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. Include supporting events such as a change in the level of activities of daily living, recent hospitalizations, and the known date of death (if you are billing for a period of time prior to the billing period in which death occurred. 0000013895 00000 n presented in the material do not necessarily represent the views of the AHA. Thus the overall rate of decline in each patient is fairly constant and predictable, unlike many other non-cancer diseases. 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 Use of CDT is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). 0000001970 00000 n Severely disabled; hospital admission is indicated although death not imminent. 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. You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. 0000025584 00000 n Part II. recommending their use. 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. You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement. West J Med. E46 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. This Agreement will terminate upon notice if you violate its terms. This section is specific for Alzheimers disease and Related Disorders, and is not appropriate for other types of dementia. This email will be sent from you to the 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. Serum creatinine > 8.0 mg/dl (>6.0 mg/dl for diabetics). All verbal abilities are lost. However, documentation expectations should comport with normal clinical documentation practices. Applicable Federal Acquisition Regulation Clauses (FARS)/Department of Defense Federal Acquisition Regulation supplement (DFARS) Restrictions Apply to Government Use. 0000060832 00000 n 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. Documentation of the applicable criteria listed under the Indications section of this policy would meet this requirement. patients with marked limitation of activity; they are comfortable only at rest. Applications are available at the AMA Web site, http://www.ama-assn.org/go/cpt. 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. Use of CDT is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. Able to carry on normal activity; minor signs or symptoms of disease. All Rights Reserved. See 1869(f)(1)(A)(i) of the Social Security Act. 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. 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.'' The AMA does not directly or indirectly practice medicine or dispense medical services. Progression from an earlier stage of disease to metastatic disease with either: A continued decline in spite of therapy; or. It does not mean, however, that meeting the guideline is obligatory. authorized with an express license from the American Hospital Association. For this reason, the history of the rate of progression in individual patients is important to obtain to predict prognosis. Circulation. such information, product, or processes will not infringe on privately owned rights. Decline in Karnofsky Performance Status (KPS) or Palliative Performance Score (PPS) from <70% due to progression of disease. K. Ogle, B. Mavis, G. Wyatt. 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. 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. endstream endobj 647 0 obj <>/Metadata 45 0 R/Pages 44 0 R/StructTreeRoot 47 0 R/Type/Catalog/ViewerPreferences<>>> endobj 648 0 obj <>/ExtGState<>/Font<>/ProcSet[/PDF/Text/ImageC]/Properties<>>>/XObject<>>>/Rotate 0/StructParents 0/TrimBox[0.0 0.0 612.0 792.0]/Type/Page>> endobj 649 0 obj <> endobj 650 0 obj <> endobj 651 0 obj [/ICCBased 686 0 R] endobj 652 0 obj [/ICCBased 687 0 R] endobj 653 0 obj <> endobj 654 0 obj <> endobj 655 0 obj <> endobj 656 0 obj <>stream While these characteristics are assessed along a continuum, rather than as discrete variables, they are useful in formulating and documenting a diagnosis of malnutrition. Our audit covered $3.4 billion in Medicare payments for 224,175 claims with a discharge date in fiscal year (FY) 2016 or 2017 that contained a severe malnutrition diagnosis code and for which removing the diagnosis code changed the diagnosis-related group (DRG). Right heart failure (RHF) secondary to pulmonary disease (Cor pulmonale) (e.g., not secondary to left heart disease or valvulopathy). 0000008075 00000 n Unable to dress without assistance. 0000037874 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. 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. Unable to care for self; requires equivalent of institutional or hospital care; disease may be progressing rapidly. The Tracking Sheet modal can be closed and re-opened when viewing a Proposed LCD. on this web site. Many patients exhibit symptoms of both disease states. 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. THE UNITED STATES GOVERNMENT AND ITS EMPLOYEES ARE NOT LIABLE FOR ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN AJ Hospice & Palliative Care, 2003; 20; 41-51. To capture use of hypocaloric PN dosing. 0000038995 00000 n The AMA does not directly or indirectly practice medicine or dispense medical services. All Rights Reserved (or such other date of publication of CPT). They are listed in order of their likelihood to predict poor survival, the most predictive first and the least predictive last. Please review and accept the agreements in order to view Medicare Coverage documents, which may include licensed information and codes. 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. 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. These situations are obvious. 0000038553 00000 n LCD - Hospice Determining Terminal Status (L34538) No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be special, incidental, or consequential damages arising out of the use of such information, product, or process. Progression of disease differs markedly from patient to patient. 26 Because the goal of dietary supplements is to provide adequate energy and protein. FAST scale. Documentation of 3, 4, and 5, will lend supporting documentation. ALS tends to progress in a linear fashion over time. 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. CPT codes, descriptions and other data only are copyright 2022 American Medical Association. J Palliative Medicine. 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. The page could not be loaded. 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. Requires occasional assistance, but is able to care for most of his personal needs. Very sick; hospital admission necessary; active supportive treatment necessary. 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. E40 refers to Kwashiorkor is severe malnutrition with nutritional edema and dyspigmentation of skin and hair. Applications are available at the AMA Web site, http://www.ama-assn.org/go/cpt. 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. routine or continuous home or inpatient, respite, or general. for diabetics); or < 15cc/min (< 20cc/min for diabetics) with comorbidity of congestive heart failure. presented in the material do not necessarily represent the views of the AHA. Applicable FARS\DFARS Restrictions Apply to Government Use. Speech ability declines to about a half-dozen intelligible words. Protein calorie malnutrition, nutritional intervention and personalized All rights reserved. Nutritional supplementation is one of the most important interventions in patients with failure to thrive. Requires assistance dressing, bathing, and toileting. 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. Patient should demonstrate both rapid progression of ALS and critical nutritional impairment. Proposed LCD document IDs begin with the letters "DL" (e.g., DL12345). The AMA is a third party beneficiary to this Agreement. 1973 May 12;1(7811):1041-2. CPT codes, descriptions and other data only are copyright 2022 American Medical Association. The former can be managed by artificial ventilation, and the latter by gastrostomy or other artificial feeding, unless the patient has recurrent aspiration pneumonia. Generalized and cortical neurologic signs and symptoms are frequently present. Progressive loss of abilities to walk, sit up, smile, and hold head up. Coding professionals would use ICD-10-CM code E43 to report severe malnutrition, also known as starvation edema. 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. Reproduced with permission. 0000022017 00000 n THE INFORMATION, PRODUCT, OR PROCESSES DISCLOSED HEREIN. THE UNITED STATES GOVERNMENT AND ITS EMPLOYEES ARE NOT LIABLE FOR ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN 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 Note: Certain cancers with poor prognoses (e.g. MACs are Medicare contractors that develop LCDs and process Medicare claims. The former can be managed by artificial ventilation, and the latter by gastrostomy or other artificial feeding, unless the patient has recurrent aspiration pneumonia. All rights reserved. Will be largely unaware of all recent events and experiences in their lives. This can be used to compare effectiveness of different therapies and to assess the prognosis in individual patients. Unintentional progressive weight loss of greater than 10% of body weight over the preceding six months. Generally unaware of their surroundings, the year, the season, etc. Intractable hyperkalemia (> 7.0) not responsive to treatment; Intractable fluid overload, not responsive to treatment. CEA, PSA); Progressively decreasing or increasing serum sodium or increasing serum potassium. 01/11/2021: At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. Progressive decline in Functional Assessment Staging (FAST) for dementia (from 7A on the FAST). ), 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. Note that two of the disease specific guidelines (HIV Disease, Stroke and Coma) establish a lower qualifying KPS or PPS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT.