Information for Health Care Providers
Medicare coverage of hospice care depends upon a physician’s certification of an individual’s prognosis of a life expectancy of six months or less if the terminal illness runs its normal course. Please note that hospice benefits are not restricted to six months as long as the patient continues to meet the criteria.
Recognizing that determination of life expectancy during the course of a terminal illness is sometimes difficult, the following medical criteria for determining prognosis for non-cancer diagnoses should aid determination of a qualifying prognosis. These admission criteria are a reasonable approach to the determination of life expectancy based on available research. These Local Coverage Determinations (LCDs) are taken from Palmetto Government Benefits Administrators (Palmetto GBA).
6.6.1 Emphysema, COPD, CHF, Pulmonary Disease
- Is the beneficiary using oxygen? How much? How often?
- What is the beneficiary’s respiration rate?
- What is the breathing status of the beneficiary? Is the breathing labored or nonlabored? How does the beneficiary’s breathing sound? Does the beneficiary have shortness of breath at rest? With conversation?
- Is the dyspnea disabling? Explain how. Does the beneficiary get short of breath on exertion? How much exertion?
- Is the beneficiary cyanotic? Where? To what extent?
- Does the beneficiary have peripheral edema?
- Has the beneficiary had chronic bronchitis and/or emphysema?
- Is the patient steroid dependent?
- Has there been a recent weight loss due to the increased caloric consumption required for breathing? Document the beneficiary’s current weight and previous weight and height.
- Is the beneficiary on antibiotics? For what?
- Is the beneficiary on other drugs? For what symptoms are the drugs being given?
- Have there been any emergency room visits or physician office visits for exacerbation of pulmonary disease process?
- Is the beneficiary on Bronchodilators and what is their response?
- Is there any recent lab work and, what are the results?
- What is the oxygen saturation on room air?
6.6.2 Cardiovascular Diseases
- Has the beneficiary had multiple hospital admissions prior to hospice admission? If so, describe reason for hospitalization and thereby, paint a picture of the beneficiary’s history and decline (include discharge summaries in the documentation).
- Does the beneficiary have chest pain? What is the beneficiary’s history of chest pain? What medications are being given to the beneficiary to control the beneficiary’s chest pain? Is the pain relieved with medication?
- Describe the beneficiary’s activity. Be specific to the individual beneficiary. Please go beyond the terms “as tolerated” and “limited” that do not clearly convey the beneficiary’s issues or problems. Is there evidence of chest pain and/or dyspnea at rest supportive of New York Heart Association Class IV?
- Are there complications that affect other organ systems?
- What is the beneficiary’s heart rate?
- Does the beneficiary have edema? To what extent? For how long?
- Does the beneficiary have congestion?
- Does the beneficiary have fluid retention?
- Document history of optimal medication therapy or reason the beneficiary cannot tolerate diuretics, vasodilators, or ace inhibitors.
- Include heart echo results or ejection fraction results if obtained.
6.6.3 Neurological Diseases Such as Alzheimer’s Disease
- Illustrate what makes this beneficiary in the terminal phase of a very long chronic disease.
- Explain how the disease has affected the systems of the body. What complications have developed?
- Has the beneficiary been assessed according to the FAST scale? Does the beneficiary rate greater than 7 on the FAST scale?
- Has the beneficiary experienced weight loss? Indicate actual weight loss and time frame of weight loss. What is the current weight and previous weight and height?
- Is the beneficiary incontinent?
- Does the beneficiary have contractures? Decubitus wounds? Other skin problems that would indicate bed bound status?
- Is the beneficiary oriented? To what extent?
- How is the beneficiary fed? Can the beneficiary feed himself/herself? Does the beneficiary have evidence of aspiration? Indicate dates if documentation indicates aspiration have occurred in the past.
- Are there any comorbid conditions and/or any secondary conditions that would render this beneficiary terminal? What structural/functional impairments contribute to the terminal condition?
- If the beneficiary has had a CVA is the Palliative Performance Scale (PPS) score less than or equal to 40? Do they meet #2 of the Stroke and Coma LCD?
6.6.4 ALS (Amyotrophic Lateral Sclerosis)
- Has the beneficiary lost function? Where? How much? Show the structural/functional impairment by detailing the beneficiary’s historic loss of function.
- Is the beneficiary unable to eat? Describe the beneficiary’s nutritional intake. Describe beneficiary’s swallowing ability.
- What is the beneficiary’s respiratory status?
- Describe the family’s desires for the beneficiary’s treatment.
6.6.5 Other Diagnoses
- No diagnoses are excluded from hospice appropriateness. Please be sure your documentation explains why the diagnosis has created a terminal prognosis. Ask yourself, “What separates Illustrate the beneficiary’s changing condition in detail. For example, show last month’s Show how the systems of the body are in a terminal condition.
- Secure a detailed explanation from the attending physician explaining why this beneficiary is now hospice appropriate.
- Does the beneficiary desire palliative therapy? Is the beneficiary declining aggressive therapy?
- What are the structural and functional impairments?
For detailed information about the Medicare coverage for a particular diagnosis, please visit the following pages on the CMS (Centers for Medicare and Medicaid Services) website.
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