Criteria for Hospice Eligibility in Georgia

 

Medicare Criteria for Hospice by Diagnosis

The criteria for hospice eligibility in Georgia (including the Atlanta metro area) is as follows:

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. Recognizing that determination of life expectancy during the course of a terminal illness is difficult, this intermediary has established medical criteria for determining prognosis for non-cancer diagnoses. These criteria form a reasonable approach to the determination of life expectancy based on available research, and may be revised, as more research is available. Coverage of hospice care for patients not meeting the criteria in this policy may be denied. However, some patients may not meet the criteria, yet still be appropriate for hospice care, because of other co-morbidities or rapid decline. Coverage for these patients may be approved on an individual consideration basis.

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:

Cancer

  1. Disease with metastases at presentation
  2. Progression from an earlier stage of disease to metastatic disease with either:
    a. A continued decline in spite of therapy
    b. Patient declines further disease-directed therapy

Cardiopulmonary Conditions

Cardiopulmonary conditions are associated with impairments, activity limitations, and disability. Their impact on any given individual depends on the individual’s over-all health status. Health status includes measures of functioning, physical illness, mental wellbeing, as well as, environmental factors, such as the availability of palliative care services. The objective of this policy is to present a framework for identifying, documenting, and communicating the unique health care needs of individuals with cardiopulmonary conditions and thus promote the over-all goal of the appropriate care for every person, every time.

Cardiopulmonary conditions may support a prognosis of six months or less under many clinical scenarios. Medicare rules and regulations addressing hospice services require the documentation of sufficient “clinical information and other documentation” to support the certification of individuals as having a terminal illness with a life expectancy of 6 or fewer months, if the illness runs its normal course. The identification of specific structural/functional impairments, together with any relevant activity limitations, should serve as the basis for palliative interventions and care-planning. Use of the International Classification of Functioning, Disability and Health (ICF) to help identify and document the unique service needs of individuals with cardiopulmonary conditions is suggested, but not required.

The health status changes associated with cardiopulmonary conditions can be characterized using categories contained in the ICF. The ICF contains domains (e.g., structures of cardiovascular and respiratory systems, functions of the cardiovascular and respiratory system, communication, mobility, and self-care) that allow for a comprehensive description of an individual’s health status and service needs. Information addressing relevant ICF categories, defined within each of these domains, should form the core of the clinical record and be incorporated into the care plan, as appropriate.

Additionally the care plan may be impacted by relevant secondary and/or co-morbid conditions. Secondary conditions are directly related to a primary condition. In the case of cardiopulmonary conditions, examples of secondary conditions could include delirium, pneumonia, stasis ulcers and pressure ulcers. Co-morbid conditions affecting beneficiaries with cardiopulmonary conditions are, by definition, distinct from the primary condition itself. An example of a co-morbid condition would be End Stage Renal Disease (ESRD).

The important roles of secondary and co-morbid conditions are described below in order to facilitate their recognition and assist providers in documenting their impact. The identification and documentation of relevant secondary and co-morbid conditions, together with the identification and description of associated structural/functional impairments, activity limitations, and environmental factors would help establish hospice eligibility and maintain a beneficiary-centered plan of care.

Secondary Conditions:

Cardiopulmonary conditions may be complicated by secondary conditions. The significance of a given secondary condition is best described by defining the structural/functional impairments – together with any limitation in activity and restriction in participation – related to the secondary condition. The occurrence of secondary conditions in beneficiaries with cardiopulmonary conditions results from the presence of impairments in such body functions as heart/respiratory rate and rhythm, contraction force of ventricular muscles, blood supply to the heart, sleep functions, and depth of respiration. These impairments contribute to the increased incidence of secondary conditions such as delirium, pneumonia, stasis ulcers and pressure ulcers observed in Medicare beneficiaries with cardiopulmonary conditions. Secondary conditions themselves may be associated with a new set of structural/functional impairments that may or may not respond/be amenable to treatment.

Ultimately, in order to support a hospice plan of care, the combined effects of the primary cardiopulmonary condition and any identified secondary condition(s) should be such that most beneficiaries with the identified impairments would have a prognosis of six months or less.

Co morbid Conditions:

The significance of a given co-morbid condition is best described by defining the structural/functional impairments – together with any limitation in activity and restriction in participation – related to the co-morbid condition. For example a beneficiary with a primary cardiopulmonary condition and ESRD could have specific ESRD-related impairments of water, mineral and electrolyte balance functions coexisting with the cardiopulmonary impairments associated with the primary cardiopulmonary condition (e.g., Aortic Stenosis, Chronic Obstructive Pulmonary Disease, or Heart Failure).

Ultimately, in order to support a hospice plan of care, the combined effects of the primary cardiopulmonary condition and any identified co-morbid condition(s) should be such that most beneficiaries with the identified impairments would have a prognosis of six months or less.

The documentation of structural/functional impairments and activity limitations facilitate the selection of the most appropriate intervention strategies (palliative/hospice versus long-term disease management) and provide objective criteria for determining the effects of such interventions. The documentation of these variables is thus essential in the determination of reasonable and necessary Medicare Hospice Services.

Alzheimer’s Disease & Related Disorders

Alzheimer’s Disease and related disorders may support a prognosis of six months or less under many clinical scenarios. The identification of specific structural/functional impairments, together with any relevant activity limitations, should serve as the basis for palliative interventions and care planning. The structural and functional impairments associated with a primary diagnosis of Alzheimer’s Disease are often complicated by co-morbid and/or secondary conditions. Co-morbid conditions affecting beneficiaries with Alzheimer’s Disease are by definition distinct from the Alzheimer’s Disease itself- examples include coronary heart disease (CHD) and chronic obstructive pulmonary disease (COPD). Secondary conditions on the other hand are directly related to a primary condition – in the case of Alzheimer’s Disease examples include delirium and pressure ulcers. The important roles of co-morbid and secondary conditions are described below in order to facilitate their recognition and assist providers in documenting their impact.

The Reisberg Functional Assessment Staging (FAST) Scale has been used for many years to describe Medicare beneficiaries with Alzheimer’s Disease and a prognosis of six months or less. The FAST Scale is a 16-item scale designed to parallel the progressive activity limitations associated with Alzheimer’s Disease. Stage 7 identifies the threshold of activity limitation that would support a six-month prognosis. The FAST Scale does not address the impact of co-morbid and secondary conditions. These two variables are thus considered separately by this policy.

FAST Scale Items:

To be eligible for hospice care, the patient needs to be at least stage 7.

Stage #7: Loss of speech, locomotion, and consciousness:

  • Sub-stage 7a: Ability to speak limited (1 to 5 words a day)
  • Sub-stage 7b: All intelligible vocabulary lost
  • Sub-stage 7c: Non-ambulatory
  • Sub-stage 7d: Unable to sit up independently
  • Sub-stage 7e: Unable to smile
  • Sub-stage 7f: Unable to hold head up

Co morbid Conditions:

The significance of a given co-morbid condition is best described by defining the structural/functional impairments – together with any limitation in activity – related to the co-morbid condition. For example a beneficiary with Alzheimer’s Disease and clinically significant CHD or COPD would have specific impairments of cardiorespiratory function (e.g., dyspnea, orthopnea, wheezing, chest pain) which may or may not respond/be amenable to treatment. The identified impairments in cardiorespiratory function would be associated with both specific structural impairments of the coronary arteries or bronchial tree and may be associated with activity limitations (e.g., mobility, self-care). Ultimately, the combined effects of the Alzheimer’s Disease (FAST stage 7 and beyond) and any co-morbid condition should be such that most beneficiaries with Alzheimer’s Disease (FAST stage 7 and beyond) and similar impairments would have a prognosis of six months or less.

Secondary Conditions:

Alzheimer’s Disease may be complicated by secondary conditions. The significance of a given secondary condition is best described by defining the structural/functional impairments – together with any limitation in activity – related to the secondary condition. The occurrence of secondary conditions in beneficiaries with Alzheimer’s Disease is facilitated by the presence of impairments in such body functions as mental functioning and movement functions. Such functional impairments contribute to the increased incidence of secondary conditions such as delirium and pressure ulcers observed in Medicare beneficiaries with Alzheimer’s Disease. Secondary conditions themselves may be associated with a new set of structural/functional impairments that may or may not respond or be amenable to treatment. Ultimately, the combined effects of the Alzheimer’s Disease (FAST stage 7 and beyond) and any secondary condition should be such that most beneficiaries with Alzheimer’s Disease and similar impairments would have a prognosis of six months or less.

The documentation of structural/functional impairments and activity limitations facilitate the selection of intervention strategies (palliative vs. curative) and provide objective criteria for determining the effects of such interventions. The documentation of these variables is thus essential in the determination of reasonable and necessary Medicare Hospice Services.

Summary:

For Beneficiaries with Alzheimer’s Disease to be eligible for hospice the individual should have a FAST level of greater than or equal to 7 and specific co-morbid or secondary conditions meeting the above criteria.

Neurological Conditions

Neurological conditions are associated with impairments, activity limitations, and disability. Their impact on any given individual depends on the individual’s over-all health status. Health status includes environmental factors, such as the availability of palliative care services. The objective of this policy is to present a framework for identifying, documenting, and communicating the unique health care needs of individuals with neurological conditions and thus promote the over-all goal of the right care for every person, every time.

Neurological conditions may support a prognosis of six months or less under many clinical scenarios. Medicare rules and regulations addressing hospice services require the documentation of sufficient clinical information and other documentation to support the certification of individuals as having a terminal illness with a life expectancy of 6 or fewer months, if the illness runs its normal course. The identification of specific structural/functional impairments, together with any relevant activity limitations, should serve as the basis for palliative interventions and care-planning. Use of the International Classification of Functioning, Disability and Health (ICF) to help identify and document the unique service needs of individuals with neurological conditions is suggested, but not required.

The health status changes associated with neurological conditions can be characterized using categories contained in the ICF. The ICF contains domains and categories (e.g., structures of the nervous system, mental functions, sensory functions and pain, neuromusculoskeletal and movement related functions, communication, mobility, and self-care) that allow for a comprehensive description of an individual’s health status and service needs. Information addressing relevant ICF categories, defined within each of these domains and categories, should form the core of the clinical record and be incorporated into the care plan, as appropriate.

Additionally, the care plan may be impacted by relevant secondary and/or co-morbid conditions. Secondary conditions are directly related to a primary condition. In the case of neurological conditions, examples of secondary conditions could include dysphagia, pneumonia, and pressure ulcers. Co-morbid conditions affecting beneficiaries with neurological conditions are, by definition, distinct from the primary condition itself, however, services aimed at the co-morbid condition may indeed be related to the palliation and/or management of the terminal condition. An example of a co-morbid condition would be Chronic Obstructive Pulmonary Disease (COPD).

The important roles of secondary and co-morbid conditions are described below in order to facilitate their recognition and assist providers in documenting their impact. The identification and documentation of relevant secondary and co-morbid conditions, together with the identification and description of associated structural/functional impairments, activity limitations, and environmental factors would help establish hospice eligibility and maintain a beneficiary-centered plan of care.

Secondary Conditions:

Neurological conditions may be complicated by secondary conditions. The significance of a given secondary condition is best described by defining the structural/functional impairments – together with any limitation in activity and restriction in participation – related to the secondary condition. The occurrence of secondary conditions in beneficiaries with neurological conditions results from the presence of impairments in such body functions as consciousness, attention, sequencing complex movements, ingestion (which includes chewing, manipulation of food in the mouth, and swallowing), muscle power, tone, and endurance. These impairments contribute to the increased incidence of secondary conditions such as dysphagia, pneumonia, and pressure ulcers observed in Medicare beneficiaries with neurological conditions. Secondary conditions themselves may be associated with a new set of structural/functional impairments that may or may not respond/be amenable to treatment.

Ultimately, in order to support a hospice plan of care, the combined effects of the primary neurological condition and any identified secondary condition(s) should be such that most beneficiaries with the identified impairments would have a prognosis of six months or less.

Co-morbid Conditions:

The significance of a given co-morbid condition is best described by defining the structural/functional impairments – together with any limitation in activity and restriction in participation – related to the co-morbid condition. For example, a beneficiary with a primary neurological condition such as Amyotrophic Lateral Sclerosis (ALS) and a co-morbidity of COPD could have specific COPD-related structural and functional impairments of respiration (e.g., structural impairments of the bronchoalveolar tree resulting in increased respiratory rate, cough and impaired gas exchange) that contribute to the activity limitations and participation restrictions already present due to the respiratory muscle weakness often observed with ALS.

Such a combination could affect the palliative care plan by contributing to the individual’s dyspnea and impaired exercise tolerance. Further description/documentation using the activities and participation component of the ICF (e.g., mobility, self-care, and interpersonal interactions and relationships), would help complete the clinical picture. Palliative care aimed at relieving the dyspnea and improving the individual’s health status would be the goal.

Ultimately, in order to support a hospice plan of care, the combined effects of the primary neurologic condition and any identified co-morbid condition(s) should be such that most beneficiaries with the identified impairments would have a prognosis of six months or less.
The documentation of structural/functional impairments, together with the observed activity limitations, facilitate the selection of the most appropriate intervention strategies (palliative/hospice vs. long-term disease management) and provide objective criteria for determining the effects of such interventions. The documentation of these variables is thus essential in the determination of reasonable and necessary Medicare Hospice Services.

Renal Care

End stage renal disease (ESRD) may support a prognosis of six months or less under many clinical scenarios. The identification of specific structural/functional impairments, together with any relevant activity limitations, should serve as the basis for palliative interventions and care planning. The structural and functional impairments associated with a primary diagnosis of ESRD are often complicated by co-morbid and/or secondary conditions. Co-morbid conditions affecting beneficiaries with ESRD are by definition distinct from the ESRD itself- examples include vascular disease manifested as coronary heart disease (CHD), peripheral vascular disease (PVD), and vascular dementia. Secondary conditions, on the other hand, are directly related to a primary condition. In the case of ESRD, examples include secondary hyperparathyroidism, calciphylaxis, nephrogenic systemic fibrosis, electrolyte abnormalities and anorexia. The important roles of co-morbid and secondary conditions are described below in order to facilitate their recognition and assist providers in documenting their impact. Use of the International Classification of Functioning, Disability and Health (ICF) is suggested, but not required.

Medicare rules and regulations require the documentation of sufficient “clinical information and other documentation” to support the certification of individuals as having a terminal illness with a life expectancy of 6 or fewer months, if the illness runs its normal course. For beneficiaries with ESRD the identification of relevant co-morbid and secondary conditions, together with the identification and description of associated structural/functional impairments, activity limitations, and environmental factors would help establish hospice eligibility and maintain a beneficiary-centered plan of care.

Secondary Conditions:

ESRD may be complicated by secondary conditions. The significance of a given secondary condition is best described by defining the structural/functional impairments – together with any limitation in activity – related to the secondary condition. The occurrence of secondary conditions in beneficiaries with ESRD is facilitated by the presence of impairments in such body functions as urinary excretory function, water, mineral and electrolyte function, and endocrine gland functions. Such functional impairments contribute to the increased incidence of secondary conditions such as hyperkalemia, fluid overload, and secondary hyperparathyroidism observed in Medicare beneficiaries with ESRD. Secondary conditions themselves may be associated with a new set of structural/functional impairments that may or may not respond/be amenable to treatment. Ultimately, the combined effects of the ESRD and any secondary condition should be such that most beneficiaries with ESRD and similar impairments would have a prognosis of six months or less.

Co-morbid Conditions:

The significance of a given co-morbid condition is best described by defining the structural/functional impairments – together with any limitation in activity – related to the co-morbid condition. For example, a beneficiary with ESRD and clinically significant CHD would have specific impairments of cardiovascular structure/function (e.g., narrowing of coronary arteries, dyspnea, orthopnea, chest pain) which may or may not respond/be amenable to treatment. The identified impairments in cardiovascular structure/function may be associated with activity limitations (e.g., mobility, self-care). Ultimately, the combined effects of the ESRD and any co-morbid condition should be such that most beneficiaries with ESRD and similar impairments would have a prognosis of six months or less.

The documentation of structural/functional impairments and activity limitations facilitates the selection of intervention strategies (palliative vs. long-term disease management/curative) and provides objective criteria for determining the effects of such interventions. The documentation of these variables is thus essential in the determination of reasonable and necessary Medicare Hospice Services.

Liver Disease

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 (1 and 2 must be present; factors from 3 will lend supporting documentation):

  1. The patient should show both a and b:
    a. Prothrombin time prolonged more than 5 seconds over control, or International Normalized Ratio (INR)> 1.5
    b.Serum albumin <2.5 gm/d1
  2. End stage liver disease is present and the patient shows at least one of the following:
    a. ascites, refractory to treatment or patient non-compliant
    b. spontaneous bacterial peritonitis
    c. hepatorenal syndrome (elevated creatinine and BUN with oliguria (<400ml/day) and urine sodium concentration <10 mEq/l)
  3. hepatic encephalopathy, refractory to treatment, or patient non-compliant
    e. recurrent variceal bleeding, despite intensive therapy
    3. Documentation of the following factors will support eligibility for hospice care:
    a. progressive malnutrition
    b. muscle wasting with reduced strength and endurance
    c. continued active alcoholism (> 80 gm ethanol/day)
    d. hepatocellular carcinoma
    e. HBsAg (Hepatitis B) positivity
    f. hepatitis C refractory to interferon treatmentPatients 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 must be discharged from hospice.

HIV

  1. CD4+ Count <25 cells/mcL or persistent viral load >100,000 copies/ml, plus one of the following:
    CNS lymphoma
    b. Untreated, or not responsive to treatment, wasting (loss of 33% lean body mass)
    c. Mycobacterium avium complex (MAC) bacteremia, untreated, unresponsive to treatment, or treatment refused
    d. Progressive multifocal leukoencephalopathy
    e. Systemic lymphoma, with advanced HIV disease and partial response to chemotherapy
    f. Visceral Kaposi’s sarcoma unresponsive to therapy
    g. Renal failure in the absence of dialysis
    h. Cryptosporidium infection
    i. Toxoplasmosis, unresponsive to therapy
  2. Decreased performance status, as measured by the Karnofsky Performance Status (KPS) scale, of ≤ 50
  3. Documentation of the following factors will support eligibility for hospice care:
    Chronic persistent diarrhea for one year
    b. Persistent serum albumin <2.5
    c. Concomitant, active substance abuse
    d. Age > 50 years
    e. Absence of antiretroviral, chemotherapeutic and prophylactic drug therapy related specifically to HIV disease
    f. Advanced AIDS dementia complex
    g. Toxoplasmosis
    h. Congestive heart failure, symptomatic at rest

Adult Failure to Thrive (AFTT)

The adult failure to thrive syndrome is characterized by unexplained weight loss, malnutrition and disability. The syndrome has been associated with multiple primary conditions (e.g., infections and malignancies), but always includes two defining clinical elements, namely nutritional impairment and disability. The nutritional impairment and disability associated with the adult failure to thrive syndrome may be severe enough to have an impact on the patient’s short-term survival.

The adult failure to thrive syndrome may manifest as an irreversible progression in the patient’s nutritional impairment/disability despite a trial of therapy (i.e., treatment intended to effect the primary condition responsible for the patient’s clinical presentation). The presence of co-morbid conditions may hasten the patient’s clinical progression and as such should be identified and addressed. This hospice policy addresses those cases where reversible causes of severe nutritional impairment and disability (i.e., the adult failure to thrive syndrome) have been excluded.

The Medicare Hospice Benefit is predicated upon physician-certification that an individual entitled to Part A of Medicare is terminally ill. An individual is considered to be terminally ill if the individual has a medical prognosis that his or her life expectancy is six months or less if the terminal illness runs its normal course. The medical criteria listed below would support a terminal prognosis for individuals with the adult failure to thrive syndrome. Medical criteria 1 and 2 are important indicators of nutritional and functional status respectively, and would thus support a terminal prognosis if met.

This diagnosis cannot be the primary or only condition.  AFTT is used to support other diagnosis.

1. The nutritional impairment associated with the adult failure to thrive syndrome should be severe enough to impact a beneficiary’s weight. It is expected that the Body Mass Index (BMI) of beneficiaries electing the Medicare Hospice Benefit for the adult failure to thrive syndrome will be below 22 kg/m 2 and that the patient is either declining enteral/parenteral nutritional support or has not responded to such nutritional support, despite an adequate caloric intake.

BMI (kg/m 2)=703 x (weight in pounds) divided by (height in inches) 2

2. The disability associated with the adult failure to thrive syndrome should be such that the individual is significantly disabled. Significant disability would be demonstrated by a Karnofsky or Palliative Performance Scale value less than or equal to 40%.

Both the beneficiary’s BMI and level of disability should be determined using measurements/observations made within six months (180 days) of the most recent certification/recertification date. If enteral nutritional support has been instituted prior to the election of the Hospice Medicare Benefit and will be continued, the BMI and level of disability should be determined using measurements/observations made at the time of the initial certification and at each subsequent recertification.

At the time of recertification recumbent measurement(s) (anthropometry) such as mid-arm muscle area in cm 2 may be substituted for BMI with documentation as to why a BMI could not be measured. This information will be subject to review on a case by case basis.

783.21 “abnormal loss of weight” and 799.4 “Cachexia” are additional secondary diagnoses which may describe the clinical circumstances of an individual beneficiary”

 

Source: Centers for Medicare & Medicaid Services LCDs as of August 2015 https://go.cms.gov/1PwFcIl