2. Objectives
Identify eligible patients early
Knowledge of LCDs
Prognosis prediction
The “new old rules” regarding debility
3. Prognostic Accuracy
Initial certification based on physician or medical
director’s best clinical judgment regarding the usual
predicted course of the disease
“Individuals who present in the same way generally die
in 6 months.”
Several studies have indicated about an 85% accuracy in
physician’s 6 month prognosis
4. Eligibility Perspectives
Medicare Language: “ 6 months prognosis or less”
Medicare Reimbursement: “about 5 months”
Physicians: “Are they going to die tonight”
Hospice Nurse: “Do they NEED us?”
Marketer: “I am pretty sure I heard them cough”
5. Eligibility Myths
Eligibility vs. Compassion
Eligibility vs. Care needed or provided
Physician referral vs. other
Cancer = Eligibility
6. Local Coverage Determinations
LCD’s
1995, LMRP devised by NHO as “general guidelines”
LCD’s might not be up to date
Different states may have different fiscal
intermediaries, so LCD’s may not be uniform
Limited Prognosis is the only real eligibility criterion.
Some patients may not meet the criteria but still be
appropriate
7. Patient Must Meet 1 of 4 Criteria
(to guarantee Medicare payment)
Meets all LCD criteria
Meets most of LCD criteria and has a documented rapid
clinical decline
Meets most of LCD criteria and has significant
comorbities
A documented provider’s clinical assessment of limited
prognosis
8. General Guidelines for all
Diagnosis (Nondisease Specific)
• Clinical progression of disease
• Performance, functional status
• Cognition
• Nutritional status
• Severity of comorbitidites
• Burden of symptoms
9. Documenting Clinical Decline
OBTAIN AND REVIEW OLD RECORDS
Get names of all of patients physicians and hospitals
Serial physical findings and diagnostic studies
Multiple recent hospitalizations, ED visits or office visits
Changes in the MDS for nursing facilities
Deterioration while receiving home health services
Failure at rehabilitation
11. Clinical Status
Recurrent or intractable infections such as pneumonia,
sepsis or upper urinary tract
Progressive inanition as documented by:
Weight loss and decreasing anthropomorphic measurements
not due to *reversible causes such as depression or diuretics
Dysphagia leading to recurrent aspiration and/or
inadequate oral intake documented by decreased
portions eaten
Progressive stages 3-4 pressure ulcers in spite of optimal
treatment
13. Signs
Systolic BP <90 or progressive postural hypotension
Ascites
Venous, arterial or lymphatic obstruction
Edema
Pleural/pericardial effusion
Weakness
Changes in level of consciousness
14. Laboratory
Incr. pCO2, decr. pO2, or decr SaO2
Incr. calcium, BUN/Cr or LFTs
Increasing tumor markers (CEA, PSA)
Abnormal electrolytes, Na+ or K+
15. Nutrition
10% weight loss in the elderly over ~6mo
BMI <22kg/m2 (BMI=703x (wt in lbs)/(ht in inches)2
Anthropomorphic measures
Arm, thigh and abdominal girth
Low serum albumin <2.5
Declines enteral or parenteral nutritional support
16. Function
Serial evaluations of ADL’s: bathing, dressing, feeding,
transfers, toileting, ambulation
IADL’s
ADL deficits are the most important predictor of 6 mo.
Mortality (at least 3/6)
KPS 50%, PPS 40%
Active symptoms
17. Comorbidities
Documenting other significant existing diseases
Document the severity and progression of these diseases
Supporting evidence for 6 mo prognosis:
Additional organ systems involved
Diseases that affect prognosis
Severity more important than the amount of comorbidities
19. Is “Debility” a hospice diagnosis?
CMS expects that hospices not use ‘debility’ or ‘adult
failure to thrive’ as the primary diagnosis
In those cases that clearly have another diagnosis that
can be considered as a principal diagnosis and as many
other diagnoses that are related or that contribute to
the patient’s terminality be included (up to 17
diagnoses may be submitted).
CMS cites that the Medicare hospice benefit requires the
hospice to cover all palliative care related to the
terminal illness and all related or contributing illnesses
20. Cancer (simplified)
KPS/PPS may be initially >50%
Aggressive, recurrant or metastatic
Unresponsive to or not a candidate for disease remitting
therapy
Patient declines further therapy
Certain cancers have poor prognosis
SCLCA, brain CA, pancreatic cancer, malignant melanoma,
stage IV hepatobiliary and gallbladder CA, stage IV renal CA
21. Cancer
Cancers with higher probability of cure
Testicular, ALL, Hodgkin’s
Cancers that may have more favorable extended
prognosis with palliative treatment even after
metastasis
Prostate, breast, MDS, CML, CLL, multiple
myeloma
23. Pulmonary Disease
1. **Severe chronic lung disease
Disabling dyspnea at rest (unresponsive to bronchodilators)
FEV1 < 30% predicted
Recurrent respiratory infections and or RF
Serial decrease of FEV1>40ml/yr
2. **Hypoxemia at rest on room air, pO2 <55mmHg, pCO2 >50%
or O2sat<88%. Patient on chronic O2
3. RHF secondary to Cor pulmonale
4. Unintentional progressive wt loss >10% in last 6 mo
5. Resting tachycardia > 100/min
24. Pulmonary Disease-Assessment
H/o VDRF
pO2/pCO2, 50/50
SaO2 <88% on room air
Elderly
<90% ideal body wt
Continuous O2
Bed-chair existence
Cough and sputum
Hypotension, BP 100/80
Resting tachycardia >100
Tachypnea
Chest wall abnormalities
Use of accessory respiratory
muscles
Cyanosis, clubbing
Edema
Wheezing, decr. BrS
25. Heart Disease
1. Patient has had maximal medical management or is not a
surgical candidate
2. NYHA IV, significant symptoms at rest---CHF or angina
1. EF <20% or diasytolic disfunction
2. Inability to carry on any physical activity without pain/SOB
3. Supportive factors
1. Resistant symptomatic SVTs or ventricular arrythmias
2. H/o cardiac arrest or resuscitation
3. H/o unexplained syncope
4. Brain embolism of cardiac origin
5. HIV disease
32. Dementia
FAST scale > 7
Unable to ambulate without
assistance
Unable to dress without
assistance
Unable to bathe without
assistance
Urinary and fecal incontinence
No consistently meaningful
verbal communication:
stereotypical phrases or <6
intelligible words
Patients should have had one of
the following in the past 12 mo
Aspiration pneumonia
Pyelonephritis
Septicemia
Decubitus ulcers, multiple stg3-
4
Fever, recurrent after antibx
10% wt loss over 6 mo
Albumin <2.5
33. Acute Stroke and Coma
Has at least one of the
following for 3 days:
Coma
PVS
Obtundation/myoclonus
Postanoxic stroke
High risk mortality after 3
days
Abnorm brainstem response
Absent verbal response
Absent withdrawal to pain
Cr >1.5
Supporting factors:
Aspiration pneumonia
Pyelonephritis
Sepsis
Refractory stage 3-4
decubitus ulcers
Recurrant fever after
antibiotics
34. Poststroke or Multiinfarct Dementia
Fast >7
One of supporting conditions
(last slide) in 3-6 months
Altered nutritional status
Dysphagia
Refusal to eat
Impaired nutritional status
despite artificial nutrition
Poor porgnostic Factors:
Nontraumatic hemorrhagic
stroke
Lg volume on CT
Ventricular extension
>30% cerebrum
Midline shift>1.5cm
Obstructive hydrocephalus
Thrombo/embolic stroke
Large ant. Infarcts
Large bihemispheric infarcts
Basilar artery occlusion
Bilateral vertebral art.
occlusion
35. ALS and other Motor Neuron Disease
Rapid Neurological Progression over 12 mo
Loss of ambulation, speech, chewing
Progressive dependence
Critically Impaired Ventilatory Capacity
VC < 30%
Dyspnea at rest
Refusal of ventillatory support
Critical Nutritional Impairment
Dysphagia or refusal to eat
**artificial nutrition or ventillation will significantly alter
prognosis
36. ALS and Motor Neuron Disease
Examination by a neurologist within 3 months to confirm
diagnosis
Supporting factors
Aspiration pneumonia
Pyelonephritis
Septicemia
Decubitus ulcers, multiple, stages III or IV
Recurrant fever after antibx
37. HIV Disease
CD4 < 25 cell/ mcl (w/o acute illness)
HIV RNA viral load >100,000 persistant or
HIV RNA viral load <100,000 plus:
Refusal of antivirals or prophlactic meds
Declining functional status, KPS < 50
CNS lymphoma
PML
Cryptosporidiosis or toxoplasmosis
AIDs wasting or AIDs dementia
MAC bacteremia
Visceral Kaposi’s sarcoma
Renal failure
38. HIV disease
Supporting Factors:
Chronic persistant diarrhea > 1yr
Alb <2.5
Substance abuse
Age >50
Symptomatic CHF at rest
Advanced liver disease
Age > 50yrs
39. Common Errors
Conclusions without objective evidence
Disease without documented symptoms
Conflicting documentation
Failure to tract S/S over time 6-12 mo
Not providing descriptive narratives
40. Burden of Illness
Age at disease onset, years of illness
Advanced age
Degree of frailty
Location/environment
CG ability
Access to healthcare providers
Secondary conditions and comorbid conditions
42. Certification
Written or oral certification of terminal illness within 2
days after the beginning of the election period
Must be signed by the hospice physician and the
patient’s attending physician
Written certification must be obtained before the claim
is sent for payment
If the patient is admitted in the 3rd benefit period or
beyond there must be a F2F encounter
43. Ineligibility
Decision of IDG, attending and medical director
Patient must be discharged when ineligibility is
determined, not end of cert period
Improvement---sustained, nonmalignant diseases wax
and wane
Remember, patients may get better
Admit often occurs after an acute event
Hospice care may improve symptoms
44. Case example #1
Mr. Jones is a 72 y/o male with multiple medical
problems including chronic renal disease due to
diabetes. His GFR ranges from 18-22%. He has had a
fistula put in one year ago but is “holding off on dialysis
until his GFR hits 16% as the “bottom limit” to have to
do dialysis. He was referred to hospice by his HMO care
case manager who states that they have seen a decline
in his condition over the last year. He has had two
recent hospitalizations. They were both for CHF with
severe scrotal edema and dyspnea. He is also a chronic
alcoholic, drinking a tall glass of scotch and vermooth
every night. On arrival to the ipu he had been without
alcohol for nearly two days and appeared completely
lucid and conversant. However when he began drinking
45. Case study (cont)
His usual nightly alcohol he became more confused and
agitated with repeated falls. His scrotal edema was
slow to resolve. The patient lives at home alone.
What other information would you like to find out?
His he hospice appropriate?
What would his hospice diagnosis be?
Can he still have dialysis?
46. Case example #2
Yvonne is a 52 y/o female with a mild mental disability
due to cerebral palsy. She had multiple hospitalizations
over the past 6-12 months for altered mental status and
seizures. She was on multidrug therapy for what
appeared to be atypical chronic seizures. With these
episodes she also had recurrent episodes of aspiration
and pneumonia. Before the most recent hospitalization
she was able to get around by a wheel chair and was
taking care of her elderly mother. She failed a swallow
study and did appear to have difficulty swallowing. She
was also very depressed because her mother was unable
to take care of her at home. She became mostly
bedbound after the last hospitalization, dependent on
5/6 ADL’s with KPS 30%.
47. Case Study (cont.)
Is this patient hospice eligible?
What further information do you want?
