Hospice Eligibility

The following are guidelines based on Local Coverage Determination (LCD) for hospice eligibility used by National Government Services(NGS), a Medicare fiscal intermediary.

Note that sometimes a patient does not specifically “fit” into one or more of the guidelines yet still has a life expectancy of six months or less. They may still be eligible for hospice. We can help you make that determination.

General End-Stage Disease Guidelines

  • Changes in clinical variables apply to patients whose decline is not considered reversible.
  • Documented decline in functional and clinical status (Both of these should be met)
  • Assistance needed with at least two Activities of Daily Living (ADLs)
  • Decline in Palliative Performance Score (PPS) < 70 (as evidenced by reduced ambulation, inability to do normal work and normal or reduced intake.)* Except for HIV (PPS 50%) and Stroke/Coma (PPS 40%) guidelines*
  • Decline in nutritional status (not due to reversible cause)
  • Unintentional progressive weight loss (10% over 6 months)
  • Serum albumin < 2.5 gm/dl
  • Dysphasia leading to recurrent aspiration and/or inadequate intake.
  • Increasing ER visits, physician visits or hospitalizations related to the hospice primary diagnosis.
  • Multiple co-morbidities.
  • Desire for Palliative Care

*Refer to PPS table

Performance Scales

Following are three performance scales that provide standardized scores for assessing the patient condition. These are the Palliative Performance Scale (PPS), the Karnofsky Performance Status Scale, and the Functional Assessment Staging (FAST) scale.

Palliative-performance-scale

Source: Intermediary-National Government Services

Karnofsky Performance Status Scale

A rating of 50% or less with HIV Disease and 40% or less with Stroke/Coma is a predictor of poor survival.

Assessment by Disease or Disorder

The following pages provide guidelines for patient condition assessment specific to certain diseases and disorders.

Alzheimer’s disease and Related Disorders (ADRD):

Includes senile dementia with delirium, Pick’s Disease, Senile degeneration of the brain. Appropriate ADRD patients should exhibit a loss of speech, locomotion and awareness as manifested through the following characteristics (consistent with FAST Scale Stage 7 and above):

  • Ability to speak limited to 1-5 words per day
  • Total loss of intelligible vocabulary
  • Non-ambulatory
  • Unable to sit up independently
  • Unable to smile
  • Unable to hold head up
  • Severely disabled to moribund (Karnofsky score >30%)

The presence of multiple co morbidities such as COPD or CHF, along with secondary conditions and rapid functional decline should also be considered and must be documented when making a case for hospice eligibility. Patients should have had one of the following in the last 12 months:

  • Aspiration pneumonia
  • Pyelonephritis
  • Septicemia
  • Decubitus ulcers, Multiple stage 3 or 4
  • Fever, Recurrent after antibiotic

Inability to maintain sufficient fluid and calorie intake with 10% weight loss during previous 6 months or serum albumin < 2.5 gm/dl

Amyotrophic Lateral Sclerosis (ALS)

Examination by a neurologist within three months of hospice referral is needed to confirm diagnosis and assist with prognosis. Patients must demonstrate these conditions:

1.Critically impaired breathing capacity (all the below conditions must exist):

  • Vital capacity (VC) less than 30% of normal
  • Significant shortness of breath at rest
  • Requiring supplemental oxygen at rest
  • Patient declines artificial ventilation

2. Rapid progression of ALS for the previous 12 months (all conditions must exist) and critical nutritional impairment:

  • Rapid progression in previous 12 months
  • Progression from independent motion to wheelchair or bed-bound status
  • Progression from normal to barely intelligible or unintelligible speech
  • Progression from normal to pureed diet
  • Progression from independence in most or all activities of daily living (ADLs) to needing assistance by caregiver in all ADLs
  • Critical nutritional impairment in previous 12 months (all conditions must exist):
    • Oral intake of nutrients and fluids insufficient to sustain life
    • Continuing weight loss
    • Dehydration or hypovolemia
    • Absence of artificial feeding methods

3. Rapid progression of ALS and life-threatening complications during the previous 12 months (one or more of the following must exist)

  • Recurrent aspiration pneumonia
  • Upper urinary tract infection
  • Sepsis or Recurrent fever after antibiotic therapy

Cancer

Patients must demonstrate these conditions:
Clinical findings of malignancy with invasive, aggressive or metastatic disease OR decline in performance status and/ or significant unintentional weigh loss

The following conditions are not required for the end-stage diagnosis but should be documented if available:

  • Evidence of malignant histopathology (define cell type)
  • Reasoning behind unavailability of neoplastic histopathology (explain basis for presumptive diagnosis)

Note: Certain cancers with poor prognosis (e.g. small cell lung cancer, brain cancer, and pancreatic cancer) may be hospice eligible without fulfilling the other criteria in this selection.

Suggested Guidelines to Consider When Referring Non-Cancer Patients to Hospice

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 terminal illness is difficult, the Centers for Medicare and Medicaid Services (CMS) 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.

Cancer patients who are determined to be hospice appropriate by their attending physician are not required to meet any other clinical guidelines. Not all hospice appropriate non-cancer diagnoses are covered in this booklet. ICD-9 codes listed are not all-inclusive. The Local Coverage Determinations (LCD’s) included in this book are provided as general eligibility guidelines for patients with non-cancerous diagnoses. The patient may not meet the criteria, yet still be appropriate for hospice care because of other co-morbidities or a rapid decline.

Cardiac – Heart Disease

Patients must demonstrate these conditions at the time of referral and initial certification:

1.Optimally treated with diuretics and vasodilators, which may include ACE inhibitors or the combination of hydralazine and nitrates, or side effects that prohibit use of these drugs must be documented in the medical record.

OR

Angina pectoris, at rest, resistant to standard nitrate therapy and are either not qualified for or decline invasive procedures.

AND

2. Significant symptoms of recurrent congestive heart failure (CHF) at rest, classified as a New York Heart Association (NYHA) Class IV:

  • Cannot carry out any physical activity without discomfort or breathlessness
  • As physical activity is undertaken, discomfort or breathlessness increases
  • Symptoms of CHF or angina are present even at rest

3. Documentation of the following factors may provide additional support for end-stage heart disease:

  • Treatment-resistant symptomatic supraventricular or ventricular arrhythmias
  • History of cardiac arrest or resuscitation
  • History of unexplained syncope
  • Brain embolism or cardiac origin
  • Concomitant HIV disease
  • Ejection fraction <20%
  • Decline in Karnofsky Performance Status Scale from 70% or less

Liver Disease

1 and 2 must be present.
1. The patient should show both a and b:

  1. PT > 5 seconds over control or INR > 1.5
  2. Serum albumin < 2.5 gm/dl

2. End stage liver disease is present and the patient shows at least one of the following:

  1. Ascites, refractactory to treatment or patient non-compliant
  2. Spontaneous bacterial peritonitis
  3. Hepatorenal syndrome: (elevated creatine and BUN with oliguria (<400 ml/day) and urine sodium concentration <10 mEq/l)
  4. Hepatic encephalopathy, refractory to treatment, or patient no-compliant
  5. Recurrent variceal bleeding despite intensive therapy

Factors which will add supporting documentation

  • Progressive malnutrition
  • Muscle wasting w/ reduced strength and endurance
  • Continued active alcoholism (>80 gm ethanol/day)
  • Hepatocellar carcinoma
  • HBsAg (Hepatitis B) positivity
  • Hepatitis C refractory to interferon treatment

ICD-9 Codes that Support Medical Necessity
155.0 Malignant Neoplasm of Liver Primary, 571.2 Alcoholic Cirrhosis of Liver
571.40 Chronic Hepatitis Unspecified, 571.41 Chronic Persistent Hepatitis
571.49 Other Chronic Hepatitis
571.5 Cirrhosis of Liver without Alcohol
571.6 Biliary Cirrhosis, 572.2 Hepatic Coma
573.3 Hepatitis Unspecified

Pulmonary Disease

Patients must demonstrate each of these conditions:

  • Disabling shortness of breath at rest, with poor or no response to bronchodilators, resulting in decreased functional ability, fatigue and cough
  • Frequent hospital admissions or ER visits for pulmonary infections and/or respiratory failure
  • Hypoxemia at rest on room air (can be documented by pO2<55 mmHg, or oxygen saturation< 88% or hypercapnia –pCO2>50 mmHG)

The following conditions are not required for the end-stage diagnosis but may be documented:

  • FEV after bronchodilator <30% of predicted
  • Cor pulmonale and right heart failure (RHF) secondary to pulmonary disease (e.g., not secondary to left heart disease or valvulopathy)
  • Steady weight loss of greater than 10% of body weight over the prior six months
  • Resting tachycardia > 100/min
  • Ventilator dependence for >72 hours during the previous year
  • CPAP or BiPAP dependence

Renal Disease

Acute or chronic patients with Renal Disease must demonstrate each of these conditions. 1, 2 and 3 must be present.

  1. The patient is not seeking dialysis or renal transplant
  2. Creatinine clearance <10 cc/min (<15 cc/min, diabetics)
  3. Serum creatinine > 8.0 mg/dl (>6.0 mg/dl for diabetics)

Factors lending supporting evidence for acute renal failure

  • Mechanical ventilation
  • Chronic lung disease
  • Advanced liver disease (sepsis, immuno-suppression/AIDS, Albumin <3.5 gm/dl, Cachexia.)
  • Malignancy (other organ system)
  • Advanced Cardiac Disease (platelet count <25,000, Disseminated intravascular coagulation and Gastrointestinal bleeding)

Factors lending supporting evidence for chronic renal failure

  • Uremia
  • Oliguria (<400 cc/day)
  • Intractable hyperkalemia (>7.0) not responsive to treatment.
  • Uremic pericarditis
  • Hepatorenal syndrome
  • Intractable fluid overload, not responsive to treatment

ICD-9 Codes that Support Medical Necessity
584.9 Acute Renal Failure Unspecified
585 Chronic Renal Failure

Stroke and Coma

Acute phase of hemorrhagic or ischemic stroke. 1, 2 or 3 must be present.

  1. Coma or persistent vegetative state beyond 3 days
  2. In post anoxic stroke, coma or severe obtundation accompanied by severe myoclonus beyond 3 days
  3. Dysphagia which prevents sufficient intake of foods and fluids to sustain life and no artificial nutrition/hydration

Chronic phase of hemorrhagic or ischemic stroke. 1, 2 or 3 must be present.

1. Post stroke dementia (all of the following)

  • Stage seven or beyond according to the FAST scale
  • Unable to ambulate without assistance
  • Unable to dress without assistance
  • Unable to bathe without assistance
  • Urinary and fecal incontinence, intermittent or constant
  • Ability to speak six or fewer intelligible words

2. Poor functional status with Karnofsky score 40% or less

3. Poor nutritional status with >10% weight loss during the previous six months or serum albumin <2.5 gm/dl

Coma (any etiology). Any 3 must be present, day three of coma

  1. Abnormal brain stem response
  2. Absent verbal response
  3. Absent withdrawal response to pain
  4. Serum creatinine > 1.5 mg/dl

HIV Disease

1 and 2 must be present.

1. CD4+ Count <25 cells/mc/L or persistent viral load >100,000 copies/ml, plus one of the following:

  • CNS lymphoma
  • Wasting (loss of 33% lean body mass)
  • Mycobacaterium avium complex bacteremia
  • Progressive multifocal leukoencephalopathy
  • Systemic lymphoma
  • Visceral Kaposi’s sarcoma
  • Renal failure in the absence of dialysis
  • Cryptosporidium infection
  • Toxoplasmosis
  • Advanced AIDS dementia complex

2. Decreased performance status, as measured by the Karnofsky Performance Status scale, of 50% or less.

Factors which will add supporting documentation

  • Chronic persistent diarrhea for one year
  • Persistent serum albumin <2.5 gm/dl
  • Concomitant, active substance abuse
  • Age > 50 years
  • Absence of antiretroviral, chemotherapeutic and prophylactic drug therapy
  • Toxoplasmosis
  • Congestive heart failure, symptomatic at rest

ICD-9 Codes that Support Medical Necessity
042 Human Immunodeficiency Virus (HIV) Disease