protein calorie malnutrition hospice criteria

Although guidelines applicable to certain disease categories are included, this LCD is applicable to all hospice patients. They are listed in order of their likelihood to predict poor survival, the most predictive first and the least predictive last. The AMA does not directly or indirectly practice medicine or dispense medical services. The Centers for Medicare & Medicaid Services (CMS), the federal agency responsible for administration of the Medicare, Medicaid CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. Recommendation: Target blood glucose range of 140 - 180 mg\dL for the general ICU population. The AMA is a third party beneficiary to this Agreement. Unable to care for self; requires equivalent of institutional or hospital care; disease may be progressing rapidly. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. Christakis N, Lamont E. Extent and determinants of error in doctors prognoses in terminally ill patients: prospective cohort study. If any physical activity is undertaken, discomfort is increased.) 26 Because the goal of dietary supplements is to provide adequate energy and protein. 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. Progression of disease differs markedly from patient to patient. 0000013895 00000 n rVjh)aV 5%TO)i='@]Rx\EM~{m.3:t.UPu]*;bSj7U 0%q3- RJT40(?9O1UsFS3*CR|lf[`s40Q\r*u22,!5jc-+z ]o s Will require some assistance with activities of daily living, e.g., may become incontinent, will require travel assistance but occasionally will display ability to familiar locations. Lupus or Rheumatoid Arthritis). Factors from 4 will lend supporting documentation.). Some older versions have been archived. You are leaving the CMS MCD and are being redirected to the CMS MCD Archive that contains outdated (No Longer In Effect) Local Coverage Determinations and Articles, You are leaving the CMS MCD and are being redirected to, For services performed on or after 10/01/2015, For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. )ndgM`.K3{daYpz:=~F~c~Cm& m& m& m& m#=#)XOz ), 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. THE UNITED STATES GOVERNMENT AND ITS EMPLOYEES ARE NOT LIABLE FOR ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials. 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%. The former can be managed by artificial ventilation, and the latter by gastrostomy or other artificial feeding, unless the patient has recurrent aspiration pneumonia. -*B Y81Ll8#\RRJvbbO:6c%^i4Ueuilos~8_i/qXlnv6L_KerIkEOL;v:5mMGzjqnfS)8UVy+YWyy~''vaOWpI.B'{0}|}|}|I,%%%%%%%%%%%%_^Az E46 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. hb``g``og`e`8 @1v'00?07)&=y a"WF9e*())vt4xLJJ 6x5;E8X>0~b !a;"cCm)'01d93f00,a``VF? o000h36(`a`h'a~6AAj@Ae\T@6 M> A beneficiary may match a guideline, but by virtue of that individual having lived for a significantly prolonged period thereafter, he/she has shown that guideline to be inadequate to predict the appropriate terminal prognosis.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 for the Evaluation and Management of Heart Failure)Stages of Heart Failure (HF)Stage APatients at high risk of developing HF because of the presence of conditions that are strongly associated with the development of HF. Manifestations in more than one of the following areas: Objective evidence of memory deficit obtained only with an intensive interview. Please enable "JavaScript" and revisit this page or proceed with browsing CMS.gov with patients with marked limitation of activity; they are comfortable only at rest. <]/Prev 527120/XRefStm 1970>> preparation of this material, or the analysis of information provided in the material. ), 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. 0000004098 00000 n 0000010879 00000 n CEA, PSA); Progressively decreasing or increasing serum sodium or increasing serum potassium. Left ventricular hypertrophy or fibrosis; left ventricular dilatation or hypocontractility; asymptomatic valvular heart disease; previous myocardial infarction. 1991;155:384-387.Reisberg B. ElderCare online. 0000037955 00000 n The score can help determine which patients can be managed in the home and which should be admitted to a hospice unit. and the State Children's Health Insurance Programs, contracts with certain organizations to assist in the administration of the Percentage of patients receiving PN in the ICU who receive 80% of estimated energy requirements or 20 kcals/kg/day and a minimum of 1.2 g protein/kg/day. Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by clicking below on the button labeled "I Accept". (1 and 2 should be present. CDT is a trademark of the ADA. 0000004185 00000 n Although ALS usually presents in a localized anatomical area, the location of initial presentation does not correlate with survival time. Decline in Karnofsky Performance Status (KPS) or Palliative Performance Score (PPS) from <70% due to progression of disease. R8Revision Effective: 05/06/2021Revision Explanation: Corrected typo in the associated information section under acute renal failure. K. Ogle, B. Mavis, G. Wyatt. Before sharing sensitive information, make sure you're on a federal government site. The AMA assumes no liability for data contained or not contained herein. Examination by a neurologist within three months of assessment for hospice is advised, both to confirm the diagnosis and to assist with prognosis. Measuring quality of life in stroke. for diabetics); or < 15cc/min (< 20cc/min for diabetics) with comorbidity of congestive heart failure. (Should fulfill 1, 2, or 3). and the State Children's Health Insurance Programs, contracts with certain organizations to assist in the administration of the The criteria refer to patients with various forms of advanced pulmonary disease who eventually follow a final common pathway for end stage pulmonary disease. OR Hypercapnia, as evidenced by pCO2 50 mmHg. CMS believes that the Internet is an effective method to share LCDs that Medicare contractors develop. Denial is dominant defense mechanism. Factors from 5 will lend supporting documentation. patients with slight, mild limitation of activity; they are comfortable with rest or with mild exertion. The population for key question 3 will only include patients with a diagnosis of protein-energy malnutrition. 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. 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. http://www.ed-online.net\. Skip to main content Skip to navigation Skip to navigation. They require no assistance with toileting and eating, but may have some difficulty choosing the proper clothing to wear. 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. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. (1 and 2 should be present. Some patients may not meet these guidelines, yet still have a life expectancy of 6 months or less. To capture use of hypocaloric PN dosing. Dysphagia leading to recurrent aspiration and/or inadequate oral intake documented by decreasing food portion consumption. 2003;20: 41-51.Ogle K, Mavis B, Wang T. Physicians and hospice care: attitudes, knowledge and referrals. Some patients decline rapidly and die quickly; others progress more slowly. Hepatic encephalopathy, refractory to treatment, or patient non-compliant; Recurrent variceal bleeding, despite intensive therapy. 1994;73:2087-2098.Hurst JW, Morris DC, Alexander RW. 2001;104:2996-3007. Thus, the overall rate of decline in each patient is fairly constant and predictable, unlike many other non-cancer diseases. These guidelines are to be used in conjunction with the Non-disease specific baseline guidelines described in Part II. been made to provide accurate and complete information, CMS does not guarantee that there are no errors in the information displayed > Learn more about the causes and symptoms. The scope of this license is determined by the AMA, the copyright holder. Patients with advanced structural heart disease and marked symptoms of HF at rest despite maximal medical therapy and who require specialized interventions. These materials contain Current Dental Terminology (CDTTM), copyright© 2022 American Dental Association (ADA). 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. Also, you can decide how often you want to get updates. Progressive stage 3-4 pressure ulcers in spite of optimal care. of every MCD page. 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. While not necessarily a contraindication to Hospice Care, the decision to institute either artificial ventilation or artificial feeding will significantly alter six-month prognosis. ; Supratentorial: greater than or equal to 50 ml. Laboratory tests in protein-calorie malnutrition. Other clinical variables not on this list may support a six-month or less life expectancy. preparation of this material, or the analysis of information provided in the material. 646 0 obj <> endobj Protein calorie malnutrition happens when you are not consuming enough protein and calories. Stage 5 (Early Dementia) Moderately severe cognitive decline. on this web site. History of increasing ER visits, hospitalizations, or physician visits related to the hospice primary diagnosis prior to election of the hospice benefit. 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. The criteria refer to patients with various forms of advanced pulmonary disease who eventually follow a final common pathway for end stage pulmonary disease. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials. National Government Services is not responsible for the continuing viability of Web site addresses listed below. Intractable hyperkalemia (> 7.0) not responsive to treatment; Intractable fluid overload, not responsive to treatment. routine or continuous home or inpatient, respite, or general. 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 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. 0000040550 00000 n descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work No memory deficit evident on clinical interviews. Baker D, Chin M, Cinquigrani M, et al. "JavaScript" disabled. 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. 0000040080 00000 n Another option is to use the Download button at the top right of the document view pages (for certain document types). 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 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 50%. No objective deficits in employment or social situations. Factors from 3 will add supporting documentation. Please note that if you choose to continue without enabling "JavaScript" certain functionalities on this website may not be available. Stroke or coma. 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. AHA copyrighted materials including the UB‐04 codes and (1 and 2 should be present. Symptoms of heart failure or of the anginal syndrome may be present even at rest. 2002;5:85-92.O'Toole DM. The 2023 edition of ICD-10-CM E46 became effective on October 1, 2022. 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. 2001;134:1097-1143.McCluskey L, Houseman G. Medicare hospice referral criteria for patients with amyotrophic lateral sclerosis: a need for improvement. recipient email address(es) you enter. 0000001587 00000 n Patient can no longer survive without some assistance. If you would like to extend your session, you may select the Continue Button. 0000029167 00000 n patient declines further disease directed therapyNote: Certain cancers with poor prognoses (e.g. The baseline guidelines do not independently qualify a patient for hospice coverage. The amendment clarified that the certification is based on a clinical judgment regarding the usual course of a terminal illness, and recognizes the fact that making medical prognostications of life expectancy is not always exact. (Class IV patients with heart disease have an inability to carry on any physical activity without discomfort. Stage 4 (Late Confusional)Moderate cognitive decline. Estimated glomerular filtration rate (GFR) <10 ml/min. By clicking below on the button labeled "I accept", you hereby acknowledge that you have read, understood and agreed to all terms and conditions set forth in this agreement. THE INFORMATION, PRODUCT, OR PROCESSES DISCLOSED HEREIN. If any physical activity is undertaken, discomfort is increased.) ), 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. forgetting where one has placed familiar objects; patient may have gotten lost when traveling to an unfamiliar location; co-workers become aware of patient's relatively low performance; word and name finding deficit becomes evident to intimates; patient may read a passage of a book and retain relatively little material; patient may demonstrate decreased facility in remembering names upon introduction to new people; patient may have lost or misplaced an object of value; concentration deficit may be evident on clinical testing. 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. Inability to maintain hydration and caloric intake with 1 of the following: weight loss >10% in the last 6 months or >7. . Include supporting events such as a change in the level of activities of daily living, recent hospitalizations, and the known date of death (if you are billing for a period of time prior to the billing period in which death occurred. Some patients may not meet these guidelines, yet still have a life expectancy of six months or less. Factors from 3 will add supporting documentation. 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. Part II. Physicians and hospice care: attitudes, knowledge, and referrals. Instructions for enabling "JavaScript" can be found here. Measurement of quality of life in patients with lung cancer in multicenter trials of new therapies. Subject to the terms and conditions contained in this Agreement, you, your employees and agents are authorized to use CDT only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. @7Eq p[3gXsm!t;ON-:5,lX`9^n:myuT.sf~RG}|^no\x XP\w( 0000000016 00000 n Coma Primary Criteria Patient with any 3 of the following on day three of coma: 1. Note that two of the disease specific guidelines (HIV Disease, Stroke and Coma) establish a lower qualifying KPS or PPS. Stage 3 (Early Confusional)Mild cognitive decline. Experiences urinary and fecal incontinence. Normal activity & work No evidence of disease, Normal activity & work Some evidence of disease, Normal activity with effort Some evidence of disease, Unable Normal Job/Work Significant disease, Unable hobby/house work Significant disease, Unable to do most activity Extensive disease, Unable to do any activity Extensive disease, Detailed Description of Each of the 7 Stages. Patients with dementia or Alzheimer's are eligible for hospice care when they show all of the following characteristics: 1. Requires considerable assistance and frequent medical care. 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. Please note that codes (CPT/HCPCS and ICD-10) have moved from LCDs to Billing & Coding Articles. The former can be managed by artificial ventilation, and the latter by gastrostomy or other artificial feeding, unless the patient has recurrent aspiration pneumonia. 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. Progression to dependence on assistance with additional activities of daily living (see Part II, Section 2). As each patient is unique, there are patients for whom a particular guideline does not match. Requires occasional assistance, but is able to care for most of his personal needs. recipient email address(es) you enter. Secondary Criteria Notes . By clicking below on the button labeled "I accept", you hereby acknowledge that you have read, understood and agreed to all terms and conditions set forth in this agreement. Revision Explanation: Annual review no changes were made. For this reason, the history of the rate of progression in individual patients is important to obtain to predict prognosis. Inability to maintain sufficient fluid and calorie intake with 10% weight loss during the previous six months or serum albumin <2.5 gm/dl . 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. (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. Although ALS usually presents in a localized anatomical area, the location of initial presentation does not correlate with survival time. 0000025584 00000 n Please do not use this feature to contact 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. Revision Explanation:Converted policy into new policy template that no longer includes coding section based on CR 10901. Protein-energy malnutrition (PEM) is classically described as 1 of 2 syndromes, marasmus and kwashiorkor, depending on the presence or absence of edema. Many patients exhibit symptoms of both disease states. A Local Coverage Determination (LCD) is a decision made by a Medicare Administrative Contractor (MAC) on whether a particular service or item is reasonable and necessary, and therefore covered by Medicare within the specific jurisdiction that the MAC oversees. Normal activity with effort; some signs or symptoms of disease. guidelines for diagnosing malnutrition, which looked at six characteristics, were first proposed in 2009 . Able to carry on normal activity; minor signs or symptoms of disease. Neither the United States Government nor its employees represent that use of accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the Factors from 4 will lend supporting documentation. Lab testing is not required to establish hospice eligibility. 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. 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. ): 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. 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. First, make sure the malnutrition meets the definition of a secondary diagnosisi.e., is there evaluation, monitoring, treatment, increased nursing care and/or increased length of stay. 0000061858 00000 n Decline in systolic blood pressure to below 90 or progressive postural hypotension, Venous, arterial or lymphatic obstruction due to local progression or metastatic disease, Laboratory (When available. Factors from 3 will add supporting documentation. xref Although coding guidelines state that only one of these criteria needs to be met . These should be documented in the clinical record. 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. Requires assistance dressing, bathing, and toileting. . THE UNITED STATES GOVERNMENT AND ITS EMPLOYEES ARE NOT LIABLE FOR ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN CPT codes, descriptions and other data only are copyright 2022 American Medical Association. 0000037443 00000 n Stage 6 (Middle Dementia) Severe cognitive decline.May occasionally forget the name of the spouse upon whom they are entirely dependent for survival. Your MCD session is currently set to expire in 5 minutes due to inactivity. The Tracking Sheet modal can be closed and re-opened when viewing a Proposed LCD. Additionally, marasmus can precede kwashiorkor. This is the American ICD-10-CM version of E46 - other international versions of ICD-10 E46 may differ. While these characteristics are assessed along a continuum, rather than as discrete variables, they are useful in formulating and documenting a diagnosis of malnutrition. This bibliography presents those sources that were obtained during the development of this policy. 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. Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by clicking below on the button labeled "I Accept". The document is broken into multiple sections. Coding professionals would use ICD-10-CM code E43 to report severe malnutrition, also known as starvation edema. It is rare occurrence in the U.S. E41 is used to report nutritional marasmus, a form of malnutrition characterized by consumption of . Medicare 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. Persons at this stage retain knowledge of many major facts regarding themselves and others. Large anterior infarcts with both cortical and subcortical involvement. 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. The AMA is a third party beneficiary to this Agreement. Revision Explanation: Annual review, no changes made. endstream endobj 657 0 obj <> endobj 658 0 obj <>stream 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. such information, product, or processes will not infringe on privately owned rights. endstream endobj 707 0 obj <>/Filter/FlateDecode/Index[47 599]/Length 42/Size 646/Type/XRef/W[1 1 1]>>stream Your MCD session is currently set to expire in 5 minutes due to inactivity. Some patients decline rapidly and die quickly; others progress more slowly. However, no single variable deteriorates at a uniform rate in all patients. 0000005335 00000 n 0000014780 00000 n H\0E This page displays your requested Local Coverage Determination (LCD). 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. All Rights Reserved. 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. Please visit the. ), 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. trailer An official website of the United States government. CEA, PSA); Progressively decreasing or increasing serum sodium or increasing serum potassium. Unspecified severe protein-calorie malnutrition. Extent and determinants of error in doctors prognoses in terminally ill patients: prospective cohort study. The AMA does not directly or indirectly practice medicine or dispense medical services.