AHA copyrighted materials including the UB‐04 codes and guidelines for diagnosing malnutrition, which looked at six characteristics, were first proposed in 2009 . 0000004185 00000 n There has been no change in coverage with this LCD revision. 646 0 obj <> endobj While not necessarily a contraindication to Hospice Care, the decision to institute either artificial ventilation or artificial feeding will significantly alter six-month prognosis. endstream endobj 659 0 obj <>stream Progression from an earlier stage of disease to metastatic disease with either:1. a continued decline in spite of therapy2. (Documentation of serial decrease of FEV1>40 ml/year is objective evidence for disease progression, but is not necessary to obtain. preparation of this material, or the analysis of information provided in the material. The criteria refer to patients with various forms of advanced pulmonary disease who eventually follow a final common pathway for end stage pulmonary disease. CEA, PSA); Progressively decreasing or increasing serum sodium or increasing serum potassium. 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. 1991;46:M139-M144.de Haan R, Aaronson A, Limburg M, et al. Stage 6 (Middle Dementia) Severe cognitive decline.May occasionally forget the name of the spouse upon whom they are entirely dependent for survival. K. Ogle, B. Mavis, T. Wang. 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. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely. 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.If a patient improves and/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. 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 Decline in Karnofsky Performance Status (KPS ) or Palliative Performance Score (PPS) due to progression of disease. of every MCD page. 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). ): Increasing pCO2 or decreasing pO2 or decreasing SaO2; Increasing calcium, creatinine or liver function studies; Increasing tumor markers (e.g. Unspecified protein-calorie malnutrition. These situations are obvious. Although ALS usually presents in a localized anatomical area, the location of initial presentation does not correlate with survival time. J Palliative Medicine. 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 would use ICD-10-CM code E42 to report severe protein-calorie malnutrition with signs of both kwashiorkor and marasmus. Malnutrition, Obesity and BMI : Medical Coding Guidelines ), 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. Progressive malnutrition, muscle wasting with dec. strength, ongoing alcoholism (>80 gm . (1 and 2 should be present, factors from 3 will lend supporting documentation. Decline in Karnofsky Performance Status (KPS) or Palliative Performance Score (PPS) from <70% due to progression of disease. Protein-calorie malnutrition (PCM) occurs when a child doesn't eat enough proteins and calories to meet nutritional needs. To submit a comment or question to CMS, please use the Feedback/Ask a Question link available at the bottom Focusing on Protein-Calorie Malnutrition Protein-Calorie Malnutrition (PCM) The prevalence of protein-calorie malnutrition varies depending on the clinical setting. J Gerontol. PDF Focusing on Protein-Calorie Malnutrition - Optum The AMA does not directly or indirectly practice medicine or dispense medical services. LCD document IDs begin with the letter "L" (e.g., L12345). Unable to care for self; requires equivalent of institutional or hospital care; disease may be progressing rapidly. 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. not endorsed by the AHA or any of its affiliates. Unspecified severe protein-calorie malnutrition. recipient email address(es) you enter. FAST scale. Goal: 90%. 5 $q`$Hx OmR1ShJ6yehl~"YQiy8{ f P?9G5RW\t Stage 4 (Late Confusional)Moderate cognitive decline. endstream endobj 657 0 obj <> endobj 658 0 obj <>stream Protein-energy malnutrition (PEM) is classically described as 1 of 2 syndromes, marasmus and kwashiorkor, depending on the presence or absence of edema. Therefore, multiple clinical parameters are required to judge the progression of ALS. Systemic hypertension; coronary artery disease; diabetes mellitus; history of cardiotoxic drug therapy or alcohol abuse; personal history of rheumatic fever; family history of cardiomyopathy. Thus a patient with metastatic small cell CA may be demonstrated to be hospice eligible with less documentation than a chronic lung disease patient. 0000008839 00000 n 0000037955 00000 n Stroke. 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. 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. 0000009983 00000 n The page could not be loaded. 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. Karnofsky Performance Status (KPS) or Palliative Performance Scale (PPS) of < 40% . No memory deficit evident on clinical interviews. Disease Specific GuidelinesNote: These guidelines are to be used in conjunction with the Non-disease specific baseline guidelines described in Part II.Cancer Diagnoses. (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. The CMS.gov Web site currently does not fully support browsers with CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. 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. 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. 0000038553 00000 n 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. However, the continuation of dialysis will significantly alter a patients prognosis, and thus potentially impact that individuals eligibility. LCDs outline how the contractor will review claims to ensure that the services provided meet Medicare coverage requirements. Creatinine clearance <10 cc/min (< 15 cc/min for diabetics); or < 15cc/min (< 20cc/min for diabetics) with comorbidity of congestive heart failure. Examination by a neurologist within three months of assessment for hospice is advised, both to confirm the diagnosis and to assist with prognosis. 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. Critical nutritional impairment as demonstrated by all the following characteristics occurring within the 12 months preceding initial hospice certification: Oral intake of nutrients and fluids insufficient to sustain life; Absence of artificial feeding methods, sufficient to sustain life, but not for relieving hunger. The Global Malnutrition Composite Score (GMCS) electronic clinical quality measure is comprised of four components reflecting inpatient malnutrition identification and care. 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. Protein calorie malnutrition is a type of undernutrition. 0000025584 00000 n 0000004098 00000 n 0000013895 00000 n Severely disabled; hospital admission is indicated although death not imminent. 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. Nutritional supplementation is one of the most important interventions in patients with failure to thrive. (1 and 2 should be present. The guidelines for LCD development are provided in Chapter 13 of the Medicare Program Integrity Manual. Circulation. PDF Malnutrition Recognition Guide Patient should demonstrate both rapid progression of ALS and critical nutritional impairment. 0000008075 00000 n ASPEN | Resources for Critical Care Clinicians startxref Patients with dementia should show all the following characteristics: Patients should have had one of the following within the past 12 months: Note: This section is specific for Alzheimers Disease and related disorders, and is not appropriate for other types of dementia, such as multi-infarct dementia. This LCD outlines coverage for hospice as indicated in the coverage and indications section. Applicable FARS\DFARS Restrictions Apply to Government Use. Factors from 4 will lend supporting documentation.). See Part III for disease specific guidelines to be used with these baseline guidelines. 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. Inability to maintain hydration and caloric intake with one of the following: Weight loss > 10% in the last 6 months or > 7.5% in the last 3 months; Current history of pulmonary aspiration not responsive to speech language pathology intervention; Sequential calorie counts documenting inadequate caloric/fluid intake; Dysphagia severe enough to prevent patient from continuing fluids/foods necessary to sustain life and patient does not receive artificial nutrition and hydration. Progression of disease differs markedly from patient to patient. hbbRc`b``3 1x4>.0 Secondary Criteria Notes . The views and/or positions Annals of Internal Medicine 2001; 134; 1097-1143. Serum creatinine > 8.0 mg/dl (>6.0 mg/dl for diabetics). 1984;2:187-193. (1 and 2 should be present. Protein-Energy Malnutrition | Nutrition Guide for Clinicians 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. Hospitals Overbilled Medicare $1 Billion by Incorrectly Assigning LCD - Hospice - Determining Terminal Status (L33393) Malnutrition in Hospitalized Adults | Effective Health Care (EHC) Program Documentation of the following factors will support eligibility for hospice care: Chronic persistent diarrhea for one year; Absence of or resistance to effective antiretroviral, chemotherapeutic and prophylactic drug therapy related specifically to HIV disease; Congestive heart failure, symptomatic at rest; Prothrombin time prolonged more than 5 seconds over control, or International Normalized Ratio (INR) > 1.5; End stage liver disease is present and the patient shows at least one of the following: Ascites, refractory to treatment or patient non-compliant; Hepatorenal syndrome (elevated creatinine and BUN with oliguria (< 400 ml/day) and urine sodium concentration < 10 mEq/l); Hepatic encephalopathy, refractory to treatment, or patient non-compliant; Recurrent variceal bleeding, despite intensive therapy. + RegVUA]rj N{ 8Qs. Muscle wasting with reduced strength and endurance; Continued active alcoholism (> 80 gm ethanol/day); Hepatitis C refractory to interferon treatment. presented in the material do not necessarily represent the views of the AHA. on this web site. ]6o?7#qij]e]#mvb:~=y1\N(QhnX- }%h=#8At#ZRUpJK$\v&$&Np\KOI&'=%Oxu}j.bJBmv;]wy'.p|Wst]M3 \;y^zLGazW@ZzLgZ\$f29o"T=c(%/&Kp:,j{L Fu G Symptoms of heart failure or of the anginal syndrome may be present even at rest. 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. AJ Hospice & Palliative Care, 2003; 20; 41-51. (1 and 2 should be present. 0000001970 00000 n If a patient improves and/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. 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. End Users do not act for or on behalf of the CMS. 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. The New York Heart Association (NYHA) Functional Classification provides a simple way of classifying heart disease (originally cardiac failure). Some older versions have been archived. Applicable FARS/HHSARS apply. 0000009368 00000 n If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816. authorized with an express license from the American Hospital Association. 0000002310 00000 n 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 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. ASPEN | Malnutrition Solution Center At the time of initial certification or recertification for hospice, the patient is or has been already optimally treated for heart disease, or are patients who are either not candidates for surgical procedures or who decline those procedures. HMn1>.`Ax! Progression from an earlier stage of disease to metastatic disease with either: A continued decline in spite of therapy; or. Protein calorie malnutrition happens when you are not consuming enough protein and calories. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely. 0000039481 00000 n Extent and determinants of error in doctors prognoses in terminally ill patients: prospective cohort study. Medicare contractors are required to develop and disseminate Local Coverage Determinations (LCDs). Persons at this stage retain knowledge of many major facts regarding themselves and others. 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. Significant congestive heart failure may be documented by an ejection fraction of 20%, but is not required if not already available. ), 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. 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. Medicare contractors are required to develop and disseminate Local Coverage Determinations (LCDs). 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. Instructions for enabling "JavaScript" can be found here. You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement. recommending their use. Use is limited to use in Medicare, Medicaid or other programs administered by the Centers for Medicare and Medicaid Services (CMS). While these characteristics are assessed along a continuum, rather than as discrete variables, they are useful in formulating and documenting a diagnosis of malnutrition. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials. such information, product, or processes will not infringe on privately owned rights. Additionally, marasmus can precede kwashiorkor. R2Revision Effective: N/ARevision Explanation: Annual review no changes made. An official website of the United States government. 0000005335 00000 n Some patients may not meet these guidelines, yet still have a life expectancy of six 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. Left ventricular hypertrophy or fibrosis; left ventricular dilatation or hypocontractility; asymptomatic valvular heart disease; previous myocardial infarction. While every effort has This Agreement will terminate upon notice if you violate its terms. Other clinical variables not on this list may support a six-month or less life expectancy. 1991;155:384-387.Reisberg B. ElderCare online. ): Patients awaiting liver transplant who otherwise fit the above criteria may be certified for the Medicare hospice benefit, but if a donor organ is procured, the patient should be discharged from hospice.F. No objective deficits in employment or social situations. Proposed LCD document IDs begin with the letters "DL" (e.g., DL12345). Evaluating cancer patients for rehabilitation potential. Examination by a neurologist within three months of assessment for hospice is advised, both to confirm the diagnosis and to assist with prognosis. 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. 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. ): G. Renal DiseasePatients 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.Acute renal failure: (1 and either 2 or 3 should be present. CPT codes, descriptions and other data only are copyright 2022 American Medical Association. patient declines further disease directed therapyNote: Certain cancers with poor prognoses (e.g. The score can help determine which patients can be managed in the home and which should be admitted to a hospice unit. 0000039022 00000 n All Rights Reserved. ), 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.) 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 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). Noticeable deficits in demanding job situations. THE INFORMATION, PRODUCT, OR PROCESSES DISCLOSED HEREIN. If you would like to extend your session, you may select the Continue Button. To submit a comment or question to CMS, please use the Feedback/Ask a Question link available at the bottom ge"^WOgr |___W+ tpIht=hozGC8 routine or continuous home or inpatient, respite, or general. CMS and its products and services are E46 - Unspecified protein calorie malnutrition E64 - Sequelae of protein calorie malnutrition. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT. Factors from 5 will lend supporting documentation. 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. Documentation of 3, 4, and 5, will lend supporting documentation. Decline in systolic blood pressure to below 90 or progressive postural hypotension; Venous, arterial or lymphatic obstruction due to local progression or metastatic disease; Increasing pCO2 or decreasing pO2 or decreasing SaO2; Increasing calcium, creatinine or liver function studies; Increasing tumor markers (e.g. The views and/or positions presented in the material do not necessarily represent the views of the AHA. Use of CDT is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). 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. 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. Applications are available at the AMA Web site, http://www.ama-assn.org/go/cpt. It was adopted by the Center for Medicare and Medicaid Services (CMS) as part of the Hospital Inpatient Quality Reporting Program and will go into effect in 2024. Revision Explanation: Annual review, no changes made. Analysis of Evidence (Rationale for Determination), LCD - Hospice - Determining Terminal Status (L33393). 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. Note, however, paragraph 3 of 'General Indications' under "Indications and Limitations of Coverage and/or Medical Necessity" regarding patients who improve or stabilize.Documentation should paint a picture for the reviewer to clearly see why the patient is appropriate for hospice care and the level of care provided, i.e., routine home, continuous home, inpatient respite, or general inpatient. 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. Accessed 01/16/2008.Schag CC, Heinrich RL, Ganz, PA. Karnofsky performance status revisited: Reliability, validity, and guidelines. This bibliography presents those sources that were obtained during the development of this policy. 0000037874 00000 n (Optimally treated means that patients who are not on vasodilators have a medical reason for refusing these drugs, e.g., hypotension or renal disease.). PDF Palliative Performance Scale (PPS) End-Stage Disease INDICATORS It was developed in British Columbia, Canada. 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. Reproduced with permission. 646 63 Part II. ), Renal DiseasePatients 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.Acute Renal Failure (1 and either 2, 3 or 4 should be present. Ogle K, Mavis B, Wang T. Hospice and primary care physicians: attitudes, knowledge, and barriers.