protein calorie malnutrition hospice 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. All billing and coding information was previously moved to the related Billing and Coding Article, A52830. 0000040858 00000 n 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. 0000160163 00000 n All Rights Reserved. You are leaving the CMS MCD and are being redirected to the CMS MCD Archive that contains outdated (No Longer In Effect) Local Coverage Determinations and Articles, You are leaving the CMS MCD and are being redirected to, For services performed on or after 10/01/2015, For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). "JavaScript" disabled. )Documentation should support the level of care being provided to the patient during the time period under review, i.e. Neither the United States Government nor its employees represent that use of H\n0)B-FZBo>9X;frYQkh!:?^rt:wn/6]rO7go7c?[\zVi/6K]9bKCO1r{O=fU%=Xfey.)2"/g6_n. Before sharing sensitive information, make sure you're on a federal government site. The page could not be loaded. Denial is dominant defense mechanism. Applications are available at the American Dental Association web site. Most facts and observations tending to suggest a greater than 6 month prognosis are predictable and apparent, such as a prolonged stay in hospice or a low immediate mortality diagnosis, as stated above. "JavaScript" disabled. West J Med. Lupus or Rheumatoid Arthritis). This Agreement will terminate upon notice if you violate its terms. Accessed 01/16/2008.Schag CC, Heinrich RL, Ganz, PA. Karnofsky performance status revisited: Reliability, validity, and guidelines. The AMA assumes no liability for data contained or not contained herein. Annals of Internal Medicine 2001; 134; 1097-1143. If your session expires, you will lose all items in your basket and any active searches. The criteria refer to patients with various forms of advanced pulmonary disease who eventually follow a final common pathway for end stage pulmonary disease. 0000014780 00000 n While every effort has Other clinical variables not on this list may support a six-month or less life expectancy. "JavaScript" disabled. Right heart failure (RHF) secondary to pulmonary disease (Cor pulmonale) (e.g., not secondary to left heart disease or valvulopathy). Creatinine clearance < 10 cc/min (<15 cc/min. 0000029167 00000 n 0000005335 00000 n 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. Please visit the. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816. not endorsed by the AHA or any of its affiliates. Reproduced with permission. 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 < 25 cells/mcl or persistent (2 or more assays at least one month apart) viral load >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 less than or equal to 50%. Please note that codes (CPT/HCPCS and ICD-10) have moved from LCDs to Billing & Coding Articles. ALS tends to progress in a linear fashion over time. + (1 and 2 should be present. 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. Studies enrolling individuals with planned admissions (e.g. E40 refers to Kwashiorkor is severe malnutrition with nutritional edema and dyspigmentation of skin and hair. Disease with distant metastases at presentation ORB. Consistent with Change Request 10901, all coding information, National coverage provisions, and Associated Information (Documentation Requirements, Utilization Guidelines) have been removed from the LCD and placed in the related Billing and Coding Article, A52830. Incontinent of urine, requires assistance toileting and feeding. E46 - Unspecified protein calorie malnutrition E64 - Sequelae of protein calorie malnutrition. The document is broken into multiple sections. ), 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. Unspecified severe protein-calorie malnutrition. This email will be sent from you to the 2000;320:469-472.Crooks V, Waller S, Smith T, Hahn TJ. All rights reserved. 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. Stage 5 (Early Dementia) Moderately severe cognitive decline. Oxford University Press. CMS believes that the Internet is an effective method to share LCDs that Medicare contractors develop. Factors from 3 will add supporting documentation. 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. Large anterior infarcts with both cortical and subcortical involvement; Upper urinary tract infection (pyelonephritis); Medicare Contractor Medical Directors' Hospice Workgroup, B. Friedman, M. Harwood, M. Shields. Applicable FARS\DFARS Restrictions Apply to Government Use. Patients with dementia should show all the following characteristics: Stage seven or beyond according to the Functional Assessment Staging Scale; Urinary and fecal incontinence, intermittent or constant; No consistently meaningful verbal communication: stereotypical phrases only or the ability to speak is limited to six or fewer intelligible words. While not necessarily a contraindication to Hospice Care, the decision to institute either artificial ventilation or artificial feeding will significantly alter six-month prognosis. 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. Symptoms Include a number of symptoms, including nausea and vomiting, dyspnea, persisting cough, fatigue, decreased cognition, diarrhea, and progressive pain Signs 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 You acknowledge that the ADA holds all copyright, trademark and other rights in CDT. This Agreement will terminate upon notice if you violate its terms. Additionally, marasmus can precede kwashiorkor. 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). copied without the express written consent of the AHA. Cancer. special, incidental, or consequential damages arising out of the use of such information, product, or process. 0000060832 00000 n 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. 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. If any physical activity is undertaken, discomfort is increased.) 1993;24:320- 327.Doyle D, Hanks G, Cherny N and Calman K. Oxford textbook of palliative medicine. There are multiple ways to create a PDF of a document that you are currently viewing. Karnofsky Performance Status (KPS) or Palliative Performance Scale (PPS) of < 40% . AHA copyrighted materials including the UB‐04 codes and No subjective complaints of memory deficit. The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. Although guidelines applicable to certain disease categories are included, this LCD is applicable to all hospice patients. This is the American ICD-10-CM version of E46 - other international versions of ICD-10 E46 may differ. 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 The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely. 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. Extent and determinants of error in doctors prognoses in terminally ill patients: prospective cohort study. Left ventricular hypertrophy or fibrosis; left ventricular dilatation or hypocontractility; asymptomatic valvular heart disease; previous myocardial infarction. Inability to maintain sufficient fluid and calorie intake in past 6 months (10% weight loss or albumin <2.5) . Diurnal rhythm frequently disturbed. Muscle wasting with reduced strength and endurance; Continued active alcoholism (>80 gm ethanol/day); Hepatitis C refractory to interferon treatment. Patients with dementia or Alzheimer's are eligible for hospice care when they show all of the following characteristics: 1. (1 and 2 should be present. 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. Please note that codes (CPT/HCPCS and ICD-10) have moved from LCDs to Billing & Coding Articles. Dysphagia severe enough to prevent the patient from receiving food and fluids necessary to sustain life, in a patient who declines or does not receive artificial nutrition and hydration. Stage 4 (Late Confusional)Moderate cognitive decline. Severity of malnutrition is based on phenotypic criteria only and requires one phenotypic criterion that meets the threshold of . 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 The document is broken into multiple sections. Critically impaired breathing capacity as demonstrated by all the following characteristics occurring within the 12 months preceding initial hospice certification: Vital capacity (VC) less than 30% of normal (if available); Patient declines mechanical ventilation; external ventilation used for comfort measures only. 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. 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 be in the terminal stage of heart disease (life expectancy of six months or less) if they meet the following criteria. Please do not use this feature to contact CMS. 0000003984 00000 n If any physical activity is undertaken, discomfort is increased.) 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. Non-disease specific baseline guidelines (both of these should be met), See appendix for disease specific guidelines to be used with these (Part II) baseline guidelines. The guidelines for LCD development are provided in Chapter 13 of the Medicare Program Integrity Manual. 0000022017 00000 n Lab testing is not required to establish hospice eligibility. Protein-Energy Malnutrition / diagnosis Serum Albumin / analysis Substances Amino Acids . ): Increasing pCO2 or decreasing pO2 or decreasing SaO2; Increasing calcium, creatinine or liver function studies; Increasing tumor markers (e.g. ), 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.) or to place. malnutrition (263.0: Malnutrition of a Moderate Degree) and severe malnutrition (262: Other Severe Protein Calorie Malnutrition). This LCD outlines coverage for hospice as indicated in the coverage and indications section. Progressive inanition is documented by several measures such as 10% body weight loss, decreased albumin, and dysphagia leading to aspiration, among others. Documentation of 3, 4, and 5, will lend supporting documentation.). LCD document IDs begin with the letter "L" (e.g., L12345). 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. (This value may be obtained from recent [within 3 months] hospital records.). These should be documented in the clinical record.These changes in clinical variables apply to patients whose decline is not considered to be reversible. All verbal abilities are lost. 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. Prognostic disclosure to patients with cancer near end of life. been made to provide accurate and complete information, CMS does not guarantee that there are no errors in the information displayed Measuring quality of life in stroke. 0000039400 00000 n All Rights Reserved (or such other date of publication of CPT). Patient is unable during interview to recall a major relevant aspect of their current lives, e.g., an address or telephone number of manyyears, the names of close family members (such as grandchildren), the name of the high school or college from which they graduated. recommending their use. 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. Patients who have current or prior symptoms of HF associated with underlying structural heart disease. Mild to moderate anxiety accompanies symptoms. 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. It does not mean, however, that meeting the guideline is obligatory. The page could not be loaded. End Users do not act for or on behalf of the CMS. CDT is a trademark of the ADA. ), 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. 0000001970 00000 n Noticeable deficits in demanding job situations. Instructions for enabling "JavaScript" can be found here. Frequently no deficit in the following areas: Inability to perform complex tasks. Generalized and cortical neurologic signs and symptoms are frequently present. While every effort has 0000001587 00000 n CMS and its products and services are not endorsed by the AHA or any of its affiliates. The patient is not seeking dialysis or renal transplant, or is discontinuing dialysis. AJ Hospice & Palliative Care. Although ALS usually presents in a localized anatomical area, the location of initial presentation does not correlate with survival time. Baseline data may be established on admission to hospice or by using existing information from records. startxref small cell lung cancer, brain cancer and pancreatic cancer) may be hospice eligible without fulfilling the other criteria in this section.Section II: Non-Cancer DiagnosesA. authorized with an express license from the American Hospital Association. documentation. Part III. CPT codes, descriptions and other data only are copyright 2022 American Medical Association. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816. recipient email address(es) you enter. Measurement of quality of life in patients with lung cancer in multicenter trials of new therapies. 708 0 obj <>stream ), HIV DiseasePatients 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. (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. Decline in Karnofsky Performance Status (KPS ) or Palliative Performance Score (PPS) due to progression of disease. 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. Protein calorie malnutrition is a type of undernutrition. The Social Security Act, Sections 1869(f)(2)(B) and 1862(l)(5)(D) define LCDs and provide information on the process. 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. presented in the material do not necessarily represent the views of the AHA. 646 0 obj <> endobj Part II. Laboratory tests in protein-calorie malnutrition. 0000008742 00000 n 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. Muscle wasting with reduced strength and endurance; Continued active alcoholism (> 80 gm ethanol/day); Hepatitis C refractory to interferon treatment. They are examples of findings that generally connote a poor prognosis. 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. ; Supratentorial: greater than or equal to 50 ml. Frequently continue to be able to distinguish familiar from unfamiliar persons in their environment. ), Hypoxemia at rest on room air, as evidenced by pO2 less than or equal to 55 mmHg, or oxygen saturation less than or equal to 88%, determined either by arterial blood gases or oxygen saturation monitors, (these values may be obtained from recent hospital records) OR hypercapnia, as evidenced by pCO2 greater than or equal to 50 mmHg. The scope of this license is determined by the AMA, the copyright holder. An educated person may have difficulty counting back from 40 by 4s or from 20 by 2s. Severely disabled; hospital admission is indicated although death not imminent. Stage 3 (Early Confusional)Mild cognitive decline. Hospice Eligibility Criteria Patient has a terminal illness with a life . Factors from 4 will lend supporting documentation.). 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. and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only Examination by a neurologist within three months of assessment for hospice is advised, both to confirm the diagnosis and to assist with prognosis. (Class IV patients with heart disease have an inability to carry on any physical activity. Unable to care for self; requires equivalent of institutional or hospital care; disease may be progressing rapidly. Your MCD session is currently set to expire in 5 minutes due to inactivity. Pulmonary Disease. Symptoms of heart failure or of the anginal syndrome may be present even at rest. Persons at this stage retain knowledge of many major facts regarding themselves and others. %PDF-1.4 % 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. General Guidelines:Documentation certifying terminal status must contain enough information to support terminal status upon review. Factors from 5 will lend supporting documentation. 0000010879 00000 n ), 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. The views and/or positions presented in the material do not necessarily represent the views of the AHA. and the State Children's Health Insurance Programs, contracts with certain organizations to assist in the administration of the The Centers for Medicare & Medicaid Services (CMS), the federal agency responsible for administration of the Medicare, Medicaid 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. Please review and accept the agreements in order to view Medicare Coverage documents, which may include licensed information and codes. Significant congestive heart failure may be documented by an ejection fraction of 20%, but is not required if not already available. To submit a comment or question to CMS, please use the Feedback/Ask a Question link available at the bottom No fee schedules, basic unit, relative values or related listings are included in CPT. Examination by a neurologist within three months of assessment for hospice is advised, both to confirm the diagnosis and to assist with prognosis. The guidelines for LCD development are provided in Chapter 13 of the Medicare Program Integrity Manual. 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. Unable to dress without assistance. Requires assistance dressing, bathing, and toileting. Nutritional supplementation is one of the most important interventions in patients with failure to thrive. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be CPT is a trademark of the American Medical Association (AMA). 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. ), (1 and either 2 or 3 should be present. 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. ), Liver DiseasePatients 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. 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. 5 $q`$Hx OmR1ShJ6yehl~"YQiy8{ f P?9G5RW\t R8Revision Effective: 05/06/2021Revision Explanation: Corrected typo in the associated information section under acute renal failure. 1993:109.Friedman B, Harwood S. Barriers and enablers to hospice referrals: an expert overview. Hepatic encephalopathy, refractory to treatment, or patient non-compliant; Recurrent variceal bleeding, despite intensive therapy. 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. The A.S.P.E.N. There is no regulation precluding patients on dialysis from electing Hospice care. CMS and its products and services are Secondary Criteria Notes . (Optimally treated means that patients who are not on vasodilators have a medical reason for refusing these drugs, e.g., hypotension or renal disease.). 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). 0000039022 00000 n This can be used to compare effectiveness of different therapies and to assess the prognosis in individual patients. The brain appears to no longer be able to tell the body what to do. 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. Baker D, Chin M, Cinquigrani M, et al. 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.

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