Karnofsky Performance Status (KPS) or Palliative Performance Scale (PPS) of < 40% . All verbal abilities are lost. Frequently there is no speech at all - only grunting. Patient should demonstrate both rapid progression of ALS and critical nutritional impairment. 0000039481 00000 n 2002;5:73-84.Hollen PJ, Gralla RJ, Dris MG, et al. These situations are obvious. This is the American ICD-10-CM version of E43 - other international versions of ICD-10 E43 may differ. CPT codes, descriptions and other data only are copyright 2022 American Medical Association. Very sick; hospital admission necessary; active supportive treatment necessary. endstream endobj 660 0 obj <>stream 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. guidelines for diagnosing malnutrition, which looked at six characteristics, were first proposed in 2009 . 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. 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. (Optimally treated means that patients who are not on vasodilators have a medical reason for refusing these drugs, e.g., hypotension or renal disease.). 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. You are leaving the CMS MCD and are being redirected to the CMS MCD Archive that contains outdated (No Longer In Effect) Local Coverage Determinations and Articles, You are leaving the CMS MCD and are being redirected to, For services performed on or after 10/01/2015, For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). Patients who have current or prior symptoms of HF associated with underlying structural heart disease. Flattening of affect and withdrawal from challenging situations occur. 5 $q`$Hx OmR1ShJ6yehl~"YQiy8{ f P?9G5RW\t 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. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. OR Hypercapnia, as evidenced by pCO2 50 mmHg. 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. These materials contain Current Dental Terminology (CDTTM), copyright© 2022 American Dental Association (ADA). malnutrition (263.0: Malnutrition of a Moderate Degree) and severe malnutrition (262: Other Severe Protein Calorie Malnutrition). 0000003984 00000 n 0000040858 00000 n 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. 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. 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. (1 and 2 should be present. Patient declines further disease directed therapy. Applicable Federal Acquisition Regulation Clauses (FARS)/Department of Defense Federal Acquisition Regulation supplement (DFARS) Restrictions Apply to Government Use. 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. required field. Protein-calorie malnutrition (PCM) occurs when a child doesn't eat enough proteins and calories to meet nutritional needs. 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. Almost always recall their own name. Patients with congestive heart failure or angina should meet the criteria for the New York Heart Association (NYHA) Class IV. The use of the New York heart association's classification of cardiovascular disease as part of the patient's complete problem list. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816. 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 (Class IV patients with heart disease have an inability to carry on any physical activity without discomfort. This bibliography presents those sources that were obtained during the development of this policy. CMS and its products and services are The score can help determine which patients can be managed in the home and which should be admitted to a hospice unit. Requires occasional assistance, but is able to care for most of his personal needs. The views and/or positions presented in the material do not necessarily represent the views of the AHA. While every effort has The CMS.gov Web site currently does not fully support browsers with ALS tends to progress in a linear fashion over time. 646 0 obj <> endobj While not necessarily a contraindication to Hospice care, the decision to institute either artificial ventilation or artificial feeding may significantly alter six month prognosis. 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. Applications are available at the American Dental Association web site. 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. MACs are Medicare contractors that develop LCDs and process Medicare claims. 0000037804 00000 n The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. 0000002163 00000 n ): 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. CMS and its products and services are not endorsed by the AHA or any of its affiliates. Factors from 5 will lend supporting documentation. 0000014923 00000 n The 2023 edition of ICD-10-CM E46 became effective on October 1, 2022. 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. 2000;320:469-472.Crooks V, Waller S, Smith T, Hahn TJ. Therefore, multiple clinical parameters are required to judge the progression of ALS. These changes in clinical variables apply to patients whose decline is not considered to be reversible. 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. CEA, PSA); Progressively decreasing or increasing serum sodium or increasing serum potassium. Evaluating cancer patients for rehabilitation potential. 0000039022 00000 n Pulmonary Disease. The former can be managed by artificial ventilation, and the latter by gastrostomy or other artificial feeding, unless the patient has recurrent aspiration pneumonia. 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. Progression of disease differs markedly from patient to patient. These are quite variable and include: Stage 7 (Late Dementia) Very severe cognitive decline. Medicare program. The baseline guidelines do not independently qualify a patient for hospice coverage.Note: The word should in the disease specific guidelines means that on medical review the guideline so identified will be given great weight in making a coverage determination. Some older versions have been archived. Dysphagia leading to recurrent aspiration and/or inadequate oral intake documented by decreasing food portion consumption. The Social Security Act, Sections 1869(f)(2)(B) and 1862(l)(5)(D) define LCDs and provide information on the process. 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. ), 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. 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. %%EOF At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. LCD document IDs begin with the letter "L" (e.g., L12345). Severely disabled; hospital admission is indicated although death not imminent. hb``g``og`e`8 @1v'00?07)&=y a"WF9e*())vt4xLJJ 6x5;E8X>0~b !a;"cCm)'01d93f00,a``VF? o000h36(`a`h'a~6AAj@Ae\T@6 M> startxref "JavaScript" disabled. All rights reserved. 0000013372 00000 n FVC < 40% predicted (seated or supine) and 2 or more of the following symptoms and/or signs: If unable to perform the FVC test patients meet this criterion if they manifest 3 or more of the above symptoms/signs. 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. End Users do not act for or on behalf of the CMS. PMID . Factors from 5 will lend supporting documentation. E. Lamont, N. Christakis. THE UNITED STATES GOVERNMENT AND ITS EMPLOYEES ARE NOT LIABLE FOR ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN 7500 Security Boulevard, Baltimore, MD 21244. Instructions for enabling "JavaScript" can be found here. 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. 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. patient declines further disease directed therapyNote: Certain cancers with poor prognoses (e.g. 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. (1 and 2 should be present. 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. copied without the express written consent of the AHA. Analysis of Evidence (Rationale for Determination), LCD - Hospice - Determining Terminal Status (L33393). 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. The 2023 edition of ICD-10-CM E43 became effective on October 1, 2022. By clicking below on the button labeled "I accept", you hereby acknowledge that you have read, understood and agreed to all terms and conditions set forth 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. 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". This is the American ICD-10-CM version of E46 - other international versions of ICD-10 E46 may differ. The two main criteria are the American Society for Parenteral and Enteral Nutrition (ASPEN) and the Global Leadership Initiative on Malnutrition (GLIM). Progressive stage 3-4 pressure ulcers in spite of optimal care. May have difficulty counting from 10, both backward and sometimes forward. The brain appears to no longer be able to tell the body what to do. Inability to maintain sufficient fluid and calorie intake in past 6 months (10% weight loss or albumin <2.5) . ), 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. To submit a comment or question to CMS, please use the Feedback/Ask a Question link available at the bottom Inability to maintain sufficient fluid and calorie intake with 10% weight loss during the previous six months or serum albumin <2.5 gm/dl . 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 . End Users do not act for or on behalf of the CMS. All billing and coding information was previously moved to the related Billing and Coding Article, A52830. - Social Security Act, Sections 1102, 1812 (a)(4) and (d); 1813 (a) (4); 1814 (a)(7) and (I); 1862 (a)(1), (6), and (9); 1861 (dd), 1871- 42 CFR Part 418- CMS Publication 100-02, Medicare Benefit Policy, Chapter 9.- CMS Publication 100-04, Medicare Claims Processing, Chapter 30. You can use the Contents side panel to help navigate the various sections. Goal: 90%. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816. Muscle wasting with reduced strength and endurance; Continued active alcoholism (>80 gm ethanol/day); Hepatitis C refractory to interferon treatment. They would use ICD-10-CM code E42 to report severe protein-calorie malnutrition with signs of both kwashiorkor and marasmus. of every MCD page. Made a technical update to this LCD to remove the empty Coding Information fields. 646 63 It was developed in British Columbia, Canada. Patients 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. (1 and 2 should be present; factors from 3 will add supporting documentation): 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. However, documentation expectations should comport with normal clinical documentation practices. The AMA does not directly or indirectly practice medicine or dispense medical services. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be ; Supratentorial: greater than or equal to 50 ml. 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. They require no assistance with toileting and eating, but may have some difficulty choosing the proper clothing to wear. J Palliative Medicine. Creatinine clearance <10 cc/min (< 15 cc/min for diabetics); or < 15cc/min (< 20cc/min for diabetics) with comorbidity of congestive heart failure. Each type may be classified as acute or chronic. 0000017107 00000 n 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. This page displays your requested Local Coverage Determination (LCD). The Palliative Performance Scale (PPS) is a modification of the Karnofsky Performance Scale intended for evaluating patients requiring palliative care. 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. 0000160163 00000 n Revision Explanation: Annual review no changes were made. The amendment clarified that the certification is based on a clinical judgment regarding the usual course of a terminal illness, and recognizes the fact that making medical prognostications of life expectancy is not always exact. J Palliative Medicine 2002; 5; 85-92. Before an LCD becomes final, the MAC publishes Proposed LCDs, which include a public comment period. Lupus or Rheumatoid Arthritis). Right heart failure (RHF) secondary to pulmonary disease (Cor pulmonale) (e.g., not secondary to left heart disease or valvulopathy). endstream endobj 659 0 obj <>stream If your session expires, you will lose all items in your basket and any active searches. All rights reserved. Progression to dependence on assistance with additional activities of daily living (see Part II, Section 2). Use of CDT is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). Some patients may not meet these guidelines, yet still have a life expectancy of 6 months or less. Patients with advanced structural heart disease and marked symptoms of HF at rest despite maximal medical therapy and who require specialized interventions. 0000029167 00000 n A hospice needs to be certain that the physician's clinical judgment can be supported by clinical information and other documentation that provide a basis for the certification of 6 months or less if the illness runs its normal course. Symptoms of heart failure or of the anginal syndrome may be present even at rest. 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. 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. Cancer. ; Obstructive hydrocephalus in patient who declines, or is not a candidate for, ventriculoperitoneal shunt. Other clinical variables not on this list may support a six-month or less life expectancy. 0000008839 00000 n The criteria refer to patients with various forms of advanced pulmonary disease who eventually follow a final common pathway for end stage pulmonary disease. There is no regulation precluding patients on dialysis from electing Hospice care. Examination by a neurologist within three months of assessment for hospice is advised, both to confirm the diagnosis and to assist with prognosis. 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 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. 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. Secondary Criteria Notes . C. Heart Disease. All Rights Reserved (or such other date of publication of CPT). Neither the United States Government nor its employees represent that use of Copyright © 2022, the American Hospital Association, Chicago, Illinois. They are listed in order of their likelihood to predict poor survival, the most predictive first and the least predictive last. End User Point and Click Amendment: 2004;7(1):47-53. 0000007316 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. 26 Because the goal of dietary supplements is to provide adequate energy and protein. In no event shall CMS be liable for direct, indirect, There has been no change in coverage with this LCD revision. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be 0000040363 00000 n The most severe malnutrition problems are associated with protein-calorie malnutrition (PCM), also known as protein-energy malnutrition or protein calorie undernutrition, which occurs in both chronic and acute forms. There are multiple ways to create a PDF of a document that you are currently viewing. Revision Explanation: Annual review no changes made. Factors from 4 will lend supporting documentation.). Part I. Although ALS usually presents in a localized anatomical area, the location of initial presentation does not correlate with survival time. 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. N. Christakis, E. Lamont. 0000005794 00000 n Reproduced with permission. Protein Calorie Malnutrition Hospice Criteria. ): Increasing pCO2 or decreasing pO2 or decreasing SaO2; Increasing calcium, creatinine or liver function studies; Increasing tumor markers (e.g. Serum creatinine > 8.0 mg/dl (>6.0 mg/dl for diabetics). Unspecified severe protein-calorie malnutrition. There is no regulation precluding patients on dialysis from electing Hospice care. As used herein, "you" and "your" refer to you and any organization on behalf of which you are acting. Coverage Indications, Limitations, and/or Medical Necessity. authorized with an express license from the American Hospital Association. Physicians and hospice care: attitudes, knowledge, and referrals. 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. )Documentation should support the level of care being provided to the patient during the time period under review, i.e. Applicable FARS/HHSARS apply. 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. An official website of the United States government. Experiences urinary and fecal incontinence. H\0E The New York Heart Association (NYHA) Functional Classification provides a simple way of classifying heart disease (originally cardiac failure). See 1869(f)(1)(A)(i) of the Social Security Act. Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, Baseline data may be established on admission to hospice or by using existing information from records. 0000011939 00000 n 2002;5:85-92.O'Toole DM. Denial is dominant defense mechanism. Unintentional progressive weight loss of greater than 10% of body weight over the preceding six months. The scope of this license is determined by the AMA, the copyright holder. No fee schedules, basic unit, relative values or related listings are included in CPT. Your MCD session is currently set to expire in 5 minutes due to inactivity. As each patient is unique, there are patients for whom a particular guideline does not match. 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.'' Clinical variables with general applicability without regard to diagnosis, as well as clinical variables applicable to a limited number of specific diagnoses, are provided. > Disabled; requires special care and assistance. 0000038836 00000 n "JavaScript" disabled. and the State Children's Health Insurance Programs, contracts with certain organizations to assist in the administration of the 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. Lose basic psychomotor skills, e.g., ability to walk, sitting and head control. Medicare contractors are required to develop and disseminate Local Coverage Determinations (LCDs). special, incidental, or consequential damages arising out of the use of such information, product, or process. The Social Security Act, Sections 1869(f)(2)(B) and 1862(l)(5)(D) define LCDs and provide information on the process. Proposed LCD document IDs begin with the letters "DL" (e.g., DL12345). 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. Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, Accessed 01/16/2008.Schag CC, Heinrich RL, Ganz, PA. Karnofsky performance status revisited: Reliability, validity, and guidelines. 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. Hepatic encephalopathy, refractory to treatment, or patient non-compliant; Recurrent variceal bleeding, despite intensive therapy. Please visit the, Progression of disease as documented by worsening clinical status, symptoms, signs and laboratory results. Annals of Internal Medicine 2001; 134; 1097-1143. 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.
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