protein calorie malnutrition hospice criteria

646 63 Please note that codes (CPT/HCPCS and ICD-10) have moved from LCDs to Billing & Coding Articles. 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. ), Stroke and ComaPatients will be considered to be in the terminal stages of stroke or coma (life expectancy of six months or less) if they meet the following criteria:Stroke, The guidelines contained in this policy are intended to help providers determine when patients are appropriate for the Medicare Hospice benefit. 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. 0000003947 00000 n Serum creatinine > 8.0 mg/dl (>6.0 mg/dl for diabetics). 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. 2002;5:73-84.Hollen PJ, Gralla RJ, Dris MG, et al. Frequently continue to be able to distinguish familiar from unfamiliar persons in their environment. Annals of Internal Medicine 2001; 134; 1097-1143. such information, product, or processes will not infringe on privately owned rights. Progressive stage 3-4 pressure ulcers in spite of optimal care. They may be incorporated by specific reference as part (or all) of the indication for recertification. 0000008630 00000 n The former can be managed by artificial ventilation, and the latter by gastrostomy or other artificial feeding, unless the patient has recurrent aspiration pneumonia. Skip to main content Skip to navigation Skip to navigation. 2002;5:85-92.O'Toole DM. Sign up to get the latest information about your choice of CMS topics in your inbox. 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). The AMA assumes no liability for data contained or not contained herein. of every MCD page. 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. 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. 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. Medicare program. Although not the primary hospice diagnosis, the presence of disease such as the following, the severity of which is likely to contribute to a life expectancy of six months or less, should be considered in determining hospice eligibility. 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. and the State Children's Health Insurance Programs, contracts with certain organizations to assist in the administration of the Factors from 5 will lend supporting documentation.). recipient email address(es) you enter. This section is specific for Alzheimers disease and Related Disorders, and is not appropriate for other types of dementia. Thus the overall rate of decline in each patient is fairly constant and predictable, unlike many other non-cancer diseases. Similarly, . Dysphagia leading to recurrent aspiration and/or inadequate oral intake documented by decreasing food portion consumption. J Palliative Medicine 2002; 5; 73-84. 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. Patients with dementia or Alzheimer's are eligible for hospice care when they show all of the following characteristics: 1. 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. Intractable hyperkalemia (> 7.0) not responsive to treatment; Intractable fluid overload, not responsive to treatment. Protein Calorie Malnutrition Severe Protein Calorie Malnutrition Moderate Protein Calorie Malnutrition Severe Protein Calorie Malnutrition Energy Intake <75% of EEE >7 days 50 % of EEE >5 days <75% of EEE 1 month <75% of EEE 1 month <75% of EEE 3 months 50% of EEE 1 month Weight Loss 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. No fee schedules, basic unit, relative values or related listings are included in CPT. 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. Revision Explanation:Converted policy into new policy template that no longer includes coding section based on CR 10901. 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). resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; CPT codes, descriptions and other data only are copyright 2022 American Medical Association. For this reason, the history of the rate of progression in individual patients is important to obtain to predict prognosis. Unable to dress without assistance. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials. patients with marked limitation of activity; they are comfortable only at rest. HUjI}iuU!v` "Y]I!T 3:NU^#={6: K]Sdl*B!XA-m2{gcm8n W)' fvtkW~e,y&2%!98kzb . Frequently no deficit in the following areas: Inability to perform complex tasks. 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. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. Progression from an earlier stage of disease to metastatic disease with either:1. a continued decline in spite of therapy2. startxref Revision Explanation: Annual review, no changes made. This bibliography presents those sources that were obtained during the development of this policy. Please do not use this feature to contact CMS. 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. Disease with distant metastases at presentation ORB. Progression from an earlier stage of disease to metastatic disease with either: A continued decline in spite of therapy; or. You can use the Contents side panel to help navigate the various sections. Surface area of involvement of hemorrhage greater than or equal to 30% of cerebrum; Midline shift greater than or equal to 1.5 cm. As used herein, "you" and "your" refer to you and any organization on behalf of which you are acting. These situations are obvious. )Documentation should support the level of care being provided to the patient during the time period under review, i.e. Journal of Palliative Medicine. 0000002894 00000 n Documentation of 3, 4, and 5, will lend supporting documentation. Requires assistance dressing, bathing, and toileting. 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. End User License Agreement: E46 - Unspecified protein calorie malnutrition E64 - Sequelae of protein calorie malnutrition. Stroke. NYHA Functional Classification for Congestive Heart FailureThe New York Heart Association (NYHA) Functional Classification provides a simple way of classifying heart disease (originally cardiac failure). Before an LCD becomes final, the MAC publishes Proposed LCDs, which include a public comment period. not endorsed by the AHA or any of its affiliates. CDT is a trademark of the ADA. Additionally, marasmus can precede kwashiorkor. (1 and 2 should be present; factors from 3 will add supporting documentation. 0000013372 00000 n The page could not be loaded. Current Dental Terminology © 2022 American Dental Association. Some patients decline rapidly and die quickly; others progress more slowly. Surface area of involvement of hemorrhage 30% of cerebrum; Obstructive hydrocephalus in patient who declines, or is not a candidate for, ventriculoperitoneal shunt. The population for key question 3 will only include patients with a diagnosis of protein-energy malnutrition. H. Stroke & ComaPatients will be considered to be in the terminal stage of stroke or coma (life expectancy of six months or less) if they meet the following criteria.Stroke: Documentation of diagnostic imaging factors which support poor prognosis after stroke include: Coma (any etiology): Comatose patients with any 3 of the following on day three of coma: Documentation of the following factors will support eligibility for hospice care: Documentation of medical complications, in the context of progressive clinical decline, within the previous 12 months, which support a terminal prognosis: This policy consolidates, simplifies and supercedes the several current hospice local medical review policies on determining terminal status previously implemented by this contractor whose references are incorporated herewith. In end-state ALS, two factors are critical in determining prognosis: ability to breathe, and to a lesser extent ability to swallow. Factors from 5 will lend supporting documentation. Lab testing is not required to establish hospice eligibility. ), 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.) 2004;7(1):47-53. CMS and its products and services are not endorsed by the AHA or any of its affiliates. Thus a patient with metastatic small cell CA may be demonstrated to be hospice eligible with less documentation than a chronic lung disease patient. 2001;104:2996-3007. 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. MACs are Medicare contractors that develop LCDs and process Medicare claims. "JavaScript" disabled. Any questions pertaining to the license or use of the CPT should be addressed to the AMA. To capture use of hypocaloric PN dosing. descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work Unintentional progressive weight loss of greater than 10% of body weight over the preceding six months. 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. National Government Services is not responsible for the continuing viability of Web site addresses listed below. (Optimally treated means that patients who are not on vasodilators have a medical reason for refusing these drugs, e.g., hypotension or renal disease.). Note: Certain cancers with poor prognoses (e.g. At least two of the six characteristics are needed for the diagnosis of malnutrition. 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. Requires considerable assistance and frequent medical care. R2Revision Effective: N/ARevision Explanation: Annual review no changes made. However, the amendment regarding the physician's clinical judgment does not negate the fact that there must be a basis for a certification. Please visit the. Non-disease specific baseline guidelines (both A and B should be met), Part III. 0000005794 00000 n This email will be sent from you to the The guidelines for LCD development are provided in Chapter 13 of the Medicare Program Integrity Manual. Hepatic encephalopathy, refractory to treatment, or patient non-compliant; Recurrent variceal bleeding, despite intensive therapy. 0000008075 00000 n While not necessarily a contraindication to Hospice care, the decision to institute either artificial ventilation or artificial feeding may significantly alter six month prognosis. Medicare contractors are required to develop and disseminate Local Coverage Determinations (LCDs). Stage 4 (Late Confusional)Moderate cognitive decline. This is the American ICD-10-CM version of E46 - other international versions of ICD-10 E46 may differ. 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. However, the continuation of dialysis will significantly alter a patients prognosis, and thus potentially impact that individuals eligibility. 0000037874 00000 n (1 and 2 should be present, factors from 3 will lend supporting documentation. LCDs outline how the contractor will review claims to ensure that the services provided meet Medicare coverage requirements. Another option is to use the Download button at the top right of the document view pages (for certain document types). 0000015750 00000 n No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be It was developed in British Columbia, Canada. and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only The use of the New York heart association's classification of cardiovascular disease as part of the patient's complete problem list. Some patients may not meet these guidelines, yet still have a life expectancy of six months or less. Made a technical update to this LCD to remove the empty Coding Information fields. Before an LCD becomes final, the MAC publishes Proposed LCDs, which include a public comment period. The criteria refer to patients with various forms of advanced pulmonary disease who eventually follow a final common pathway for end stage pulmonary disease. ), 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. 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. xref 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. AbstractMedicare 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. In addition, an administrative law judge may not review an NCD. Pyelonephritis or other upper urinary tract infection; Inability to maintain sufficient fluid and calorie intake with 10% weight loss during the previous six months or serum albumin <2.5 gm/dl. It places patients in one of four categories, based on how much they are limited during physical activity: patients with no limitation of activities; they suffer no symptoms from ordinary activities. 0000006339 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. 0000037443 00000 n Although ALS usually presents in a localized anatomical area, the location of initial presentation does not correlate with survival time. Dependence on assistance for two or more activities of daily living (ADLs): Co-morbidities although not the primary hospice diagnosis, the presence of disease such as the following, the severity of which is likely to contribute to a life expectancy of six months or less, should be considered in determining hospice eligibility. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. 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. Factors from 4 will lend supporting documentation. At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. 5 $q`$Hx OmR1ShJ6yehl~"YQiy8{ f P?9G5RW\t Other clinical variables not on this list may support a six-month or less life expectancy. ACC/AHA Guidelines for the evaluation and management of chronic heart failure in the adult: executive summary, a report of the American college of cardiology/American heart association task force on practice guidelines (committee to revise the 1995 guidelines of the evaluation and management of heart failure).

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