Some diseases have a fairly standard progression. For instance, patients with more advanced Alzheimer’s disease may experience changes in their ability to ambulate, to speak, or to swallow. Other illnesses, however, have less well-documented stages. Additionally, sometimes a patient’s diagnosis is not clear-cut.

1. Hospice Guidelines
Some diseases have a fairly standard progression. For instance, patients with
more advanced Alzheimer’s disease may experience changes in their ability
to ambulate, to speak, or to swallow. Other illnesses, however, have less well-
documented stages. Additionally, sometimes a patient’s diagnosis is not clear-
cut.
The Centers for Medicare and Medicaid Services (CMS) has
established Local Coverage Determination guidelines that help medical
professionals gauge the appropriateness of hospice for a patient. These
include:
1. Progression of disease
2. Decline in Karnofsky Performance Status (KPS) or Palliative
Performance Score (PPS) from <70% due to progression of disease.
3. Increasing emergency room visits, hospitalizations, or physician’s visits
related to hospice primary diagnosis
4. Progressive decline in Functional Assessment Staging (FAST) for
dementia (from ≥7A on the FAST)
5. Progression to dependence on assistance with additional activities of
daily living (See Part II, Section 2)
6. Progressive stage 3-4 pressure ulcers in spite of optimal care

2. It is important to note that CMS recognizes that, even given the LCD
guidelines, an accurate prediction is, in most cases, not possible. Thus, the
physician’s assessment and recommendation to hospice should be made
based on a patient’s specific circumstances.
According to the National Center for Biotechnology Information (CBI):
Fear of being accused of Medicare fraud by attesting incorrectly to a
limited prognosis probably keeps many honest and caring physicians
from appropriate, timely referral for the hospice benefits to which
patients are entitled. However, the Medicare Claims Processing Manual,
Chapter 11 (revised in April 2010) advises fiscal intermediaries, “It
should be noted that predicting life expectancy is not always exact.”
Incorrect prognoses made in good faith do not serve as the basis for
fraud investigations.
If you are considering whether to refer a patient for hospice care, a Shining
Light Hospice caregiver would be happy to conduct an evaluation of whether
hospice is recommended given the patient’s status.
If you have questions about hospice care in Las Vegas,
please contact Shining Light Hospice. We can provide
answers, suggest resources, and walk you through the
process of initiating hospice care, from talking with your
doctor to paying for hospice care.