Disease-Specific Hospice Eligibility
and Recertification Assessment and
Documentation
NHPCO CTC 2012
Terri Maxwell PhD, APRN
VP, Strategic Initiatives
Weatherbee Resources, Inc.
Hospice Education Network, Inc.
DISCLOSURE
• Presenter discloses no financial
relationships with a commercial entity
producing healthcare-related products
and/or services.
• This presentation is for educational and
informational purposes only. It is not
intended to provide legal, technical or
other professional services or advice.
OBJECTIVES
At the end of this session, participants will be able to:
1. Identify and utilize the correct LCD, based on the
patient’s terminal diagnosis
2. Describe clinical documentation criteria that supports
disease-specific clinical eligibility
3. Name the clinical data points necessary to substantiate
hospice eligibility for dementia, debility, and
cardiopulmonary conditions.
4. Identify “secondary” and” comorbid” conditions
associated with common disease states
ELIGIBILITY
• Medicare hospice coverage depends upon
a physician’s certification of a life
expectancy of 6 months or less if the
terminal illness runs its normal course
ELIGIBILITY, CONT’D
•The physician’s clinical judgment must be
supported by “clinical information and other
documentation” that provide a basis for a
life expectancy of six months or less
•Medical necessity must be evaluated and
clearly and objectively documented in the
clinical record
ELIGIBILITY, CONT’D
• Recognizing that determination of life
expectancy during the course of a terminal
illness is difficult, CMS established LCD
guidelines (“medical criteria”) for
determining prognosis for cancer and noncancer diagnoses
• LCD= “Local Coverage Determination”
ELIGIBILITY, CONT’D
• LCD guidelines
– Created to assist in determining eligibility
based upon disease severity and burden of
illness.
– Allows for decline of the beneficiary’s
condition be to a factor in determining
prognosis.
– Many do not reflect current research or
medical information on prognosis.
ELIGIBILITY, CONT’D
• Hospice coverage for patients not meeting
LCD guidelines may be denied
– Some patients may not meet the criteria,
yet are deemed “hospice appropriate”
because of co-morbidities or rapid
decline
– Coverage for these patients may be
approved on an individual basis
LCD
PART I:
Decline in clinical status guidelines:
Appropriate for all diagnoses
• Clinical status: weight loss, infections,
↓ albumen or cholesterol, dysphagia
• Symptoms: dyspnea, cough, poorly
controlled nausea, diarrhea, increasing
pain
• Signs: ↓BP, ascites, edema, pleural
effusion, weakness, Change in LOC
PART I, CONT’D
• Laboratory: ↑pCO2, ↓pO2, ↓O2 sat, etc.
• KPS or PPS < 70%
• ↑ ER or physician visits, ↑
hospitalizations
• FAST score 7A or >
• ↑ dependence for ADLs
• Stage III-IV pressure ulcers
PART II
•
Non-disease specific baseline guidelines –
both A and B should be met
A. Physiologic impairment of functional status
as demonstrated by:
• Karnofsky Performance Status (KPS) or
Palliative Performance Score (PPS) <
70% (HIV Disease, Stroke and Coma
establish a lower qualifying KPS or PPS).
B. Dependence on assistance for 2 or more
activities of daily living (ADLs)
PART II, CONT’D
NOTE: The baseline guidelines (Part II) do not
independently qualify a patient for hospice
coverage.
COMORBIDITIES
Although not the primary hospice
diagnosis, the presence of diseases
such as the following, the severity of
which is likely to contribute to a life
expectancy of six months or less,
should be considered in determining
hospice eligibility:
PART II/III
COMORBIDITIES
• COPD
• CHF
• Ischemic Heart Disease
• DM
• Neurologic (CVA. ALS, MS, Parkinson’s)
• Renal
• Liver
• Cancer
• AIDS
• Dementia
PART III: NGS, CGS, NHIC
DISEASE-SPECIFIC GUIDELINES
• Cancer
• ALS
• Alzheimer’s and related disorders
• Heart disease*
•Pulmonary disease*
• HIV
• Liver disease
•Renal disease
• Stroke or Coma
Palmetto
DISEASE-SPECIFIC GUIDELINES
• Cancer
• ALS
• Alzheimer’s Dementia
• Cardiopulmonary
• HIV
• Liver disease
• Renal care
• Neurological Conditions
DOCUMENTATION
• All certification (admission) and recertification
documentation must contain enough information
to support the patient’s terminal status upon
review (by an outside party such NGS, CGS,
Palmetto).
• All clinical indicators of decline that form the
basis for certifying / recertifying the patient
should be documented.
DOCUMENTATION, CONT’D
• Recertification for hospice care requires the
same clinical standards be met as for initial
certification.
• Documentation should “paint a picture” of why /
how the patient is appropriate for hospice as
well as the level of care being provided.
• Documentation should include observations and
measurable data, not merely conclusions.
DOCUMENTATION, CONT’D
• Patients with…long term survival in hospice, or
apparent stability, can still be eligible for hospice
benefits.
• If this is the case, sufficient justification for a less
than 6-month prognosis should appear in the
record.
• Inconsistent documentation should be
specifically addressed and explained, including
findings suggestive of a > 6-month prognosis.
CASE EXAMPLE
Mrs. Turner is an 88 yr. old with
a diagnosis of dementia. She
weighs 92 lbs., eats little and is
totally dependent in all ADLs.
She’s not speaking and is
sleeping a lot. She was
hospitalized two weeks ago for a
UTI.
Is she hospice appropriate?
Terminal vs. Custodial Conditions
• A 265 lb man who is losing weight does not
equate with terminal frailty, even if he is
disabled.
• Gradual worsening of cognition or ADL status or
periodic behavioral issues in patients with
dementia- in the absence of choking/aspiration,
Stage III/IV pressure ulcers, etc.
• Refer to specific requirements in the LCD
guidelines to help guide prognostication.
Terminal vs. Custodial
“Is this patient receiving terminal or custodial
care?”
•If your documentation doesn’t reflect a 6 month or
less prognosis (usually evidenced by clinical
decline) you are at risk for payment denial.
•Don’t wait until the recertification date to
discharge an ineligible patient.
Distinguishing Chronically
from Terminally Ill
“There was no indication in the submitted
documentation that beneficiary’s life expectancy
was 6 months or less. There was no
documentation of co morbidities that would have
contributed to a short life expectancy. The
documentation shows that the patient required full
time custodial care, but not the services of
Hospice”.
Comments extracted from a de-identified ZPIC
finding
DOCUMENTATION, CONT’D
• There are patients for whom a particular LCD
guideline does not match; and/or
• An LCD may be inadequate to predict the
terminal prognosis of an individual patient who
meets the guideline at the SOC and continues to
do so over a prolonged period (> than 6
months).
• In such cases, it is important to use Part I:
Decline in clinical status guidelines to document
all factors that support the terminal prognosis.
DOCUMENTING ELIGIBILITY FOR
DEBILITY
• General Decline:
– Patients demonstrating significant functional and
nutritional decline that cannot be attributed to a
primary clinical condition. (ICD9 is Adult Failure to
Thrive)
• General Decline: Use Part 1 Guidelines
– General decline patients should have low levels of
function (KPS/PPS 40-50%)
– Decline in a specific condition (ex. Alzheimer’s) which
doesn’t meet that condition’s eligibility criteria should
not be admitted as “general decline”.
DOCUMENTING ELIGIBILITY FOR
DEBILITY: Recommendation
• If there are multiple major medical
problems present, choose one of them as
a primary diagnosis.
– Use the remaining co-morbids to support a poor
prognosis
– Document clinical decline as supporting data
• This may be preferable to having a lot of patients
on under “general debility”.
BEGINNING THE ASSESSMENT:
HOSPICE REFERRAL
• What prompted your call today?
– Identify the precipitating event resulting in
hospice referral now
• How has the patient changed over the past 12
months?
– Establish baseline and illness trajectory
(type and momentum)
ANSWER THE QUESTION:
WHY HOSPICE? WHY NOW?
• What triggered the referral?
– Change in condition?
– Hospitalization?
– New or worsening symptoms?
– New or worsening co-morbidity?
– Need for additional care?
– Change in cg status or setting of care?
ENVIRONMENT OF CARE
Environmental issues that facilitate or impede care
• Caregiver availability
• Caregiver ability
• Adaptive equipment
• Financial issues
• High/low intensity of available healthcare
providers
BURDEN OF ILLNESS AND
“NORMAL COURSE OF ILLNESS”
Burden of illness and factors that influence the
“normal course” of illness
• Inter-related secondary and comorbid
conditions
• Advanced age
• Degree of frailty
• Environment of care
• Access to other healthcare providers
CLINICAL ELIGIBILITY
The clinical presentation for determining terminal
status should include the following:
• Impairment in the structure and function of
body systems
• Decline in activity and functional status
• Secondary conditions
• Comorbid conditions
SECONDARY CONDITIONS
Conditions that are directly related to
and occur as a result of the primary
condition
SECONDARY CONDITIONS
Examples of conditions that are directly related to
the terminal illness:
• Dysphagia is a secondary condition of dementia
• Dyspnea is a secondary condition of CHF
Examples of a conditions that manifest as a result
of the terminal condition:
• Decubitus ulcer is a secondary condition of coma
• Pneumonia is a secondary condition of ALS
COMORBID CONDITIONS
Diseases or conditions that are distinct from the primary
diagnosis, but may contribute to the patient’s life
expectancy.
• The terminal diagnosis of Alzheimer’s Disease with
comorbidities of Rheumatoid Arthritis and Diabetes
•
•
•
The terminal diagnosis of CHF with comorbid COPD
The terminal diagnosis of FTT with comorbid renal
insufficiency
When supporting prognosis: It isn’t the number of
co-morbid conditions but the severity that counts.
HOSPICE PATIENTS –
DISEASE TRAJECTORIES
RAPID DECLINE
– Cancer
Decline
SAW-TOOTHED DECLINE
– Organ system failures
(COPD, Heart Failure, etc.)
SLOW INSIDIOUS DECLINE
– Neurodegenerative
disorders
– Dementia
– Debility
Death
Time
Resource: Field MJ, Cassel CK (eds), Institute of Medicine.
Approaching Death: Improving Care at the End-of-life.
Washington, DC: National Academy Press. 1997
TRAJECTORIES OF ILLNESS TO DEATH:
Predictable Terminal Phase
Illnesses such
as cancer
have a
progression
that ends in a
steady
inexorable
decline in
function until
death
• Decline: Short period
of evident decline
•Death
•Time
•Resource: Field MJ, Cassel CK (eds), Institute of Medicine. Approaching Death: Improving Care at the End-of-life. Washington, DC: National
Academy Press. 1997
CANCER DIAGNOSES
Eligibility Criteria
Documentation must demonstrate that the
patient meets
• Part II Non-disease specific baseline
guidelines
AND
• Cancer guidelines in Part III/appendix
PLUS
• Comorbid conditions in Part II/III, if
applicable
CANCER Eligibility Criteria, CONT’D
•
•
•
•
KPS or PPS < 70%
Dependent in 2/6 ADLs
Metastases at presentation OR
Progression from an earlier stage of disease to
metastatic disease with either
– A continued decline in spite of therapy; or
– Patient declines further directed therapy.
Note: Certain cancers with poor prognoses (e.g., small cell
lung, brain and pancreatic cancer) may be hospice
eligible without fulfilling the other criteria.
REFERRAL # 1
1.
•
•
•
•
•
Mr. Jones:
DX: Glioblastoma
Age: 46
Residence: Home
PCG: Wife (3 children, all under 7 yrs old)
PTA: On the job injury; PMH is unremarkable;
6’3”; 235 #; BMI = 29% (overweight)
• Secondary Conditions: Headache, dizziness,
nausea. Co-Morbid Conditions- None
ADMISSION NOTE
• S – Pt reports, “I can’t believe this is happening.
I get hit in the head and find out that I have a
tumor. My doctor says the chemo and radiation
treatments are no longer working. How is my
wife going to cope with three kids by herself? My
head’s throbbing, I can’t focus my eyes, and I
want to throw up all the time. What am I going to
do?”
• O – Pt in darkened room, holding head in both
hands and grimacing at slightest noise
ADMISSION NOTE, CONT’D
• Admitted 4/18/12 w/ Glioblastoma. Fully and
completely meets Medicare eligibility:
– Terminal diagnosis
– Life expectancy of six months or less if the
disease runs its normal course (as certified by
the pt’s attending and hospice physician)
– Opting for a palliative rather than curative
approach to end-of-life care (per hospice
election and advance directives)
MEASURABLE DATA POINTS
Pt: Mr. Jones DX: Glioblastoma SOC: 4/18/12
MEASURE
PTA
4/18/12
Weight / BMI (5’10”)
-
235 / 33.7%
KPS/PPS
-
70%
NYHA or FAST
-
N/A
ADLs
Independent
Independent
Skin
Intact
Intact
Infection
-
-
TRAJECTORY OF ILLNESS:
Prolonged Insidious Progression
Typical course of debility,
Alzheimer’s and related
disorders, Stroke &
Coma, etc.
Decline:
prolonged dwindling
Steady progressive
disability leading to
death
Death
Time
Resource: Field MJ, Cassel CK (eds), Institute of Medicine. Approaching Death: Improving Care at the End-of-life. Washington, DC: National
Academy Press. 1997
DEMENTIA
• Irreversible, progressive brain disease that
slowly destroys memory, thinking, and motor
skills.
• Caused by various diseases and conditions
DEMENTIA SUBTYPES
• Alzheimer's– Most common type
• 60-80% of cases
– Results from deposits of protein plaques and
tangles in the brain
• Vascular dementia (multi-infarct dementia)
– 15-30% cases
RISK FACTORS FOR
VASCULAR DEMENTIA
• Hypertension
• Peripheral arterial disease
• Diabetes mellitus
NOTE: When a patient is admitted to hospice with vascular
dementia, the conditions above are generally considered
“related” and their associated therapies should be
covered by hospice
DEMENTIA SUBTYPES CONT’D
• Lewy Body dementia
– 10-15% cases
• Frontotemporal dementia
– <1% cases
• Parkinson’s Disease w/ dementia
– Occurs in 20-40% of patients with PD
– Risk rises in patients with PD for > 8 yrs
Natural History of AD Progression
Olson, 2003
ALZHEIMER’S & RELATED DISORDERS
GUIDELINES
Patient’s with Alzheimer’s Disease should have:
• KPS or PPS < 70%
• Minimally dependent in 2/6 ADLs
• FAST score of 7 or beyond and one of the
following w/in past 12 months:
ALZHEIMER’S, CONT’D
•
•
•
•
•
•
Aspiration pneumonia;
Pyelonephritis;
Septicemia;
Multiple stage 3-4 Decubitus ulcers;
Fever, recurrent after antibiotics;
10% weight loss during previous six months OR
serum albumin < 2.5gm/dl.
FUNCTIONAL ASSESSMENT SCALE
“FAST”
• Stage 7: Loss of speech, locomotion, and
consciousness
• Sub-stages include:
– 7a: Ability to speak limited (1-5 words/day)
– 7b: All intelligible vocabulary lost
– 7c: Non-ambulatory
– 7d: Unable to sit up independently
– 7e: Unable to smile
– 7f: Unable to hold head up
ALZHEIMER’S, CONT’D
• Frequent UTIs as a result of incontinence or
Foley catheter placement is insufficient to
demonstrate eligibility without at least one other
secondary condition.
• Documentation of weight loss OR appetite
decline helps to “paint the picture” of decline.
REFERRAL # 2
2.
•
•
•
•
•
Mrs. Doe:
DX: Dementia
Age: 96
Residence: SNF
PCG: Facility staff; granddaughter
PTA: 10-year dementia history; aspiration
pneumonia; refusing food; 5’9”; 89#; BMI=13%
(underweight)
• Secondary: Cachexia & 2 Stage III Decubitus
Ulcers
• Comorbid: Cardiac & NIDDM
ADMISSION NOTE
• S – PCG reports, “She’s not talking or looking
at me very much these days and I don’t know
why or if something is wrong.”
• O – Pt makes minimal eye contact during visit;
occasionally turns head when name is called;
can verbalize but speech is limited to < 6 words
(usually unintelligible / non-meaningful).
ADMISSION NOTE, CONT’D
• Admitted 4/18/07 w/Dementia. Fully and
completely meets LCD guidelines :
– FAST 7a (speech limited to <6 words)
– Secondary conditions:
• KPS 40%
• Dependent on PCG for 3 of 6 ADLs
ADMISSION NOTE, CONT’D
– More secondary conditions:
• Stage III wounds
• Aspiration pneumonia
– Co-morbid conditions:
• Cardiac Disease
• Diabetes
MEASURABLE DATA POINTS
Pt: Mrs. Doe DX: Dementia SOC: 2/28/12
MEASURE
PTA
2/28/12
Weight / BMI (5’8”)
-
89 / 13.5%
KPS
-
50%
NYHA or FAST
-
7a
ADLs
Amb, transfer w/1,
incontinent of B&B
Amb, transfer w/1,
incontinent of B&B
Skin
Stage III (R)
shoulder, hip & heel
Stage III (R)
shoulder, hip & heel
Infection
Aspiration
pneumonia
-
DECLINE IN HEALTH STATUS
(Debility or Adult Failure to Thrive)
• Use Part I of the LCD guideline, addressing as
many of the nine domains as appropriate
• Typically characterized by unexplained weight
loss, malnutrition and disability severe enough to
impact on the patient’s short-term survival
DECLINE IN HEALTH STATUS, CONT’D
• 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, which
should be identified and documented.
DECLINE IN HEALTH STATUS, CONT’D
• Nutritional impairment severe enough to
impact on weight.
– BMI below 22 kg/m2*
– Patient is either declining enteral / parenteral
nutritional support or has not responded to
such nutritional support, despite an adequate
caloric intake
*BMI (kg/m2) = 703 x (weight in pounds)
divided by (height in inches)2
DECLINE IN HEALTH STATUS, CONT’D
• Significant disability demonstrated by a
KPS or PPS score of 40% or less
• Both the patient’s BMI and level of disability
should be determined using measurements /
observations made within the past 6 (rolling)
months
DECLINE IN HEALTH STATUS, CONT’D
• If enteral nutritional support was instituted prior
to the hospice election – 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.
DECLINE IN HEALTH STATUS, CONT’D
• Body structure and functional impairment of the
digestive system
• Body structure and functional impairment of the
neuromusculoskeletal system
• Clinical components
 Unexplained weight loss
 Malnutrition
 Disability
REFERRAL # 3
3.
•
•
•
•
•
Mr. Adams:
DX: Debility
Age: 85
Residence: SNF
PCG: Facility staff; elderly wife
PTA: weight loss; loss of interest in life; prefers
to stay in bed; requires family assistance with
personal care; too weak to walk without 2
people assisting
ADMISSION NOTE
• S – Son reports, “He has lost all interest in life.
He’s not eating, he’s losing weight. The
pneumonia just took all his energy.”
• O – Pt lethargic; in bed; weight loss AEB baggy
pants, belt buckled on tightest hole; incontinent
B&B at night; confused; thinks he is at son’s
home; stage III wound on (R) hip.
MEASURABLE DATA POINTS
Pt: Mr. Adams DX: Debility SOC: 6/10/12
MEASURE
PTA
6/10/12
Weight / BMI (5’8”)
150
115 / 17.5%
KPS
-
40%
NYHA or FAST
-
6e
ADLs
Independent
Amb with assist,
incontinent of B&B
Skin
Intact
Stage III (R) hip
Infection
Pneumonia 4/30/12
-
TRAJECTORY OF ILLNESS:
“SAW-TOOTHED”
• Cardio-pulmonary and
other organ system
failures / conditions
(HIV, Liver, Renal, etc.)
• A slow incremental
decline punctuated by
multiple episodes of
acute exacerbations
Decline:
never get back to
previous baseline
Death
Time
Resource: Field MJ, Cassel CK (eds), Institute of Medicine. Approaching Death: Improving Care at the End-of-life. Washington, DC: National
Academy Press. 1997
PULMONARY DISEASE GUIDELINES
•
•
The patient with terminal lung disease presents
with serious respiratory failure symptoms
despite intervention with all the recommended
therapies.
The dying trajectory resembles a “saw tooth,”
with periods of compensation, subsequent
crisis, followed by compensation until death.
PULMONARY DISEASE, CONT’D
1 and 2 should be present:
1. Severe chronic lung disease with
– Disabling dyspnea at rest (e.g., bed to chair
existence, fatigue, cough)
– Progression of disease with increased ER visits
and/or hospitalizations for pulmonary
infections/respiratory failure, or increased physician
visits
2. Hypoxemia at rest with PO2 55mmHg or
oxygen saturation < 88%
PULMONARY DISEASE, CONT’D
The following lend support to the terminal
prognosis:
• Cor pulmonale (rt-sided heart failure secondary
to pulmonary disease)
• Unintentional progressive weight loss of greater
than 10% body weight over the preceding six
months
• Resting tachycardia > 100/min
PULMONARY DISEASE:
Secondary and Comorbid Conditions
Secondary conditions:
• Delirium
• Pneumonia
• Weight loss
• Decubitus ulcers
• Peptic ulcers
Comorbid conditions:
• How do the comorbid conditions impact the
terminal disease trajectory?
REFERRAL # 4
4. Mr. Smith:
• Age: 76
• DX: COPD
• Residence: Home
• PCG: Wife
• PTA: 56-year smoking history; declines
cessation Rx; 5’9”; 120#; BMI=17.7%
(underweight)
• Secondary condition: Cachexia, dyspnea,
cough
• Comorbid condition: Hypertension
MEASURABLE DATA POINTS
Pt: Mr. Smith DX: COPD SOC: 9/20/12
MEASURE
PTA
9/20/12
Weight / BMI (5’9”)
140
120 / 17.7%
KPS/PPS
-
50%
NYHA or FAST
-
-
ADLs
-
Amb, transfer,
dressing and bathing
Skin
-
-
Infection
Pneumonia
-
Oxygen
PRN
3L cont / 90%
ADMISSION NOTE
• S – Pt reports, “I can’t do anything anymore
and I’m totally exhausted all of the time. I can’t
catch my breath, even when I’m sitting doing
nothing.”
• O – Using accessory muscles & purse-lipped
breathing; push of speech noted; dyspnea @
rest; amb X 50 feet w/o rest 2 months ago; now
rests 5-10 min after only 10 feet; uses W/C with
PCG assist to maneuver in house (too weak to
self-propel); O2 @ 3L via NC; sat = 88% RA.
ADMISSION NOTE, CONT’D
• Admitted 2/20/12 w/COPD. Fully and
completely meets Pulmonary Disease LCD
guidelines:
– Structural and Functional Limitations
• KPS 50%
• Dependent on PCG for 4 of 6 ADLs
• Impaired mobility
ADMISSION NOTE, CONT’D
• Impaired respiratory function
• Dyspnea at rest
• Purse-lipped breathing
• Push of speech
• O2 sat = 88% RA
• Resting tachycardia > 100/min
ADMISSION NOTE, CONT’D
Secondary conditions:
• Pneumonia
• Bed-to-chair existence
• Extreme fatigue
• Productive cough
• Dyspnea with poor response to medication
• Oxygen-dependent
ADMISSION NOTE, CONT’D
Prior to hospice admit:
• Increasing MD & ER visits w/hospitalization
for infections
• Respiratory failure (6/28/12)
Additional supporting documentation:
• Unintentional progressive weight loss of >
10% of total body weight over last 6 months
Heart Disease
• Heart failure: Progressive disorder
resulting from an underlying disease
causing structural or functional damage to
the heart
– Weakening the heart’s pumping function
HEART DISEASE GUIDELINES
• Patient has been optimally treated for heart
disease, or is not a candidate or declines
surgical procedures. (Optimally treated means
that patients who are not on vasodilators have a
medical reason for refusing these drugs, e.g.,
hypotension or renal disease.)
• Exhibit NYHA Class IV disease.
• Ejection fraction of < 20% (Note: not required if
not available)
New York Heart Association (NYHA)
Classification
NYHA Classification
Class I
Patients have no limitation in physical activity
Class II
Patients have slight limitation of physical activity
Class III
Patients have marked limitation of physical activity
Class IV
Patients have symptoms even at rest and are
unable to carry on any physical activity without
discomfort
HEART DISEASE, CONT’D
• The following are not required, but help to
establish hospice eligibility:
– Treatment-resistant symptomatic SVT;
– History of cardiac arrest or resuscitation;
– History of unexplained syncope;
– Brain embolism of cardiac origin; and
– Concomitant HIV disease
HEART DISEASE, CONT’D
The patient with terminal heart failure has
refractory heart failure and serious heart
failure symptoms remain, despite using
all recommended therapies.
The terminal disease trajectory resembles a
“saw tooth” with periods of compensation,
subsequent crisis, followed by compensation
until death.
HEART DISEASE:
Comorbid and Secondary Conditions
Comorbid conditions:
• How does the comorbid condition impact the
terminal disease trajectory?
Secondary conditions:
• Dypsnea
• Depression
• Pneumonia
• Renal failure
• Venous stasis ulcers
HEART DISEASE:
Eligibility Assessment
• 75 yo male with HX CAD; post-hospitalization following
M.I.
• Optimally treated with Lisinopril, Lasix, and Digoxin;
• Resting vital signs: 100/52 - 88 – 22;
• Supplemental oxygen continuously at 2 liters via nasal
cannula.
• C/O feeling tired all the time; “winded”, able to ambulate
10 feet with 5 min recovery time.
• Loss of 10 pounds in past month. Normal weight: 175
pounds; current weight: 165 pounds; height 5’10”; BMI:
23.7.
• 2-3+ pitting edema BLE
• Ejection fraction: 20% during last hospitalization
ADMISSION NOTE, CONT’D
• Admitted 5/25/12 w/HF. Fully and completely
meets Heart Disease LCD guidelines:
– Structural and Functional Limitations
• NYHA Class IV optimally treated w/
significant symptoms at rest
• KPS 50%
• Dependent on PCG for 4 of 6 ADLs
• O2 dependent
Diagnoses without an LCD guideline
• There are patients for whom there is no particular
LCD guideline: or
• The LCD guideline does not match and/or
• An LCD guideline may be inadequate to predict
the terminal prognosis of an individual patient who
meets the guideline at the SOC and continues to
do so over a prolonged period (> than 6 months)
Diagnoses without an LCD, CONT’D
• In these cases, it is important to document all factors
that support the terminal prognosis:
– functional status
– secondary conditions
– comorbid conditions
• The documentation should paint a picture of
terminality, as opposed to chronicity
•Ongoing documentation of decline is required for
recertification
Interdisciplinary Group Meetings
During IDG meetings (and outside of IDG meetings), all
patients should be assessed to ensure that they continue
to meet the LCDs. Remember to check with the patient’s
Hospice Aide or volunteer about changes in functional
abilities.
Explain periods of stability for specific disease processes:
• “Ms. X is experiencing the ‘saw tooth trajectory’ that
is common with congestive heart failure; however,
she has declined since 12/21/11, as evidenced by her
decline in functional status, and her continued lower
extremity edema despite an increase in Lasix.”
RECERT DOCUMENTATION
RECERTIFICATION
• Per LCD guidelines:
– Decline in status from admission is not
necessarily required unless it is part of the LCD
or rapid decline was part of the initial certification.
– If this is the case, sufficient justification for a less
than 6-month prognosis should be documented in
the record.
– Inconsistent documentation should be specifically
addressed and explained, including findings
suggestive of a > 6-month prognosis.
RECERTIFICATION, CONT’D
– There are patients for whom a particular LCD
guideline does not match; and/or
– An LCD may be inadequate to predict the
terminal prognosis of an individual patient
who meets the guideline at the SOC and
continues to do so over a prolonged period (>
than 6 months)
– In these cases, it is important to document all
factors that support the terminal prognosis
RECERTIFICATION, CONT’D
– Recertification for hospice care requires the
same clinical standards be met as for initial
certification
– Documentation should “paint a picture” of
how/why the patient is appropriate for hospice
as well as the level of care being provided
– Documentation should include observations
and measurable data, not merely
conclusions.
RECERTIFICATION, CONT’D
• All certification (admission) and recertification
documentation must contain enough information
to support the patient’s terminal status upon
review
• All clinical indicators of decline that form the
basis for certifying / recertifying the patient must
be documented:
– By the IDG (not just nurses)
– At every visit
RECERTIFICATION, CONT’D
• Document:
– Physician & IDG discussions and decisions,
especially with regard to hospice eligibility
– “Related” and “unrelated” conditions
– Progress toward goals
RECERTIFICATION, CONT’D
• At recertification, all patients should be
considered in light of:
– Appropriateness
• Are interventions, behaviors and choices
palliative in nature and consistent with the
hospice philosophy and plan of care?
– Eligibility
• Does the disease trajectory (pattern and
momentum of decline) still reflect a
terminal condition?
RECERTIFICATION, CONT’D
• All patients, especially those with non-cancer
diagnoses, should be assessed for:
– Hospitalization risk
– Recertification potential
– Possible discharge
• A patient does not become ineligible overnight
• Discharge is a process not an event
• A period of stability must be assessed in light
of its potential to continue
RECERTIFICATION, CONT’D
•
•
•
•
•
•
•
•
•
Use LCD guidelines
Tell the story / paint the picture in words
Document for someone who does not know pt
Support ongoing hospice eligibility & limited
prognosis
What are the palliative treatments that hospice
is providing?
Documentation must stand alone
Compare to baseline data (decline over time)
Visit notes / assessments support eligibility
Describe the “normal” course of illness for the
individual patient
RECERTIFICATION, CONT’D
• Eligibility, cont’d.
– Are clinically significant secondar /comorbid
conditions present?
• If yes, what are they and how do they impact
limited prognosis?
– What is the patient’s overall burden of
illness?
– What other variables are influencing the
“normal course” of illness for this patient?
– Does patient still meet LCD guidelines?
• If yes, how?
• If no, what now, why and when?
CHALLENGES
• Ensure that documentation in the clinical record,
at admission and recertification is:
– Sufficient and consistent across all disciplines
(including physicians), visits, assessments,
and IDG meeting notes
– Based on current LCDs
– Supportive of hospice appropriateness and
eligibility (limited prognosis)
DETERMINATIONS
IDG DECISION
IDG ACTION
1. Pt fully &
Recertify – Document how pt meets LCD (CGS:
completely meets Specify Part I, or Parts II and III combined).
LCD guidelines
2. Pt partially
meets LCD
guidelines
If pt has documented symptomatic
secondary/comorbid conditions sufficient to support
limited life expectancy, recertify (document as noted
above).
3. Pt partially
meets LCD
guidelines
If pt has NO documented symptomatic
secondary/comorbid conditions sufficient to support
limited life expectancy, consider “MD Baseline
Assessment”, DX change, and/or discharge.
4. Pt does not
meet LCD
guidelines
Consider “MD Baseline Assessment”, DX change,
and/or discharge.
If the Patient no longer meets the
LCDs…
• Consider a physician baseline assessment
• Does the patient meet criteria for another LCD; if so,
change the diagnosis
•
•
•
•
Physician order for new diagnosis
Physician Narrative
New plan of care
Change billing codes
• Discharge the patient
• Discharge should not be a surprise, the patient should
be aware of the potential for discharge if they “stabilize”
or become “chronic”
• Custodial care patients are not necessarily terminal
• Do not wait for the end of the certification period
• The patient has a right to appeal the discharge
Recert Case Example
1. Ms. Doe:
• DX: Dementia
• Age: 96
• Residence: SNF
• PCG: Facility staff; granddaughter
• PTA: 20-year dementia history; aspiration
pneumonia; refusing food; 5‘9”; 89#; BMI=13%
(underweight)
• Comorbid Conditions: Cardiac & NIDDM
• Secondary Conditions: None
RECERTIFICATION: MRS. DOE
DX: Alzheimer’s disease
DATA
PTA
SOC
1ST
RECERT
2nd
RECERT
KPS / PPS
-
50%
50%
50%
FAST
-
7a
7a
7a
NYHA
-
N/A
N/A
N/A
ADLs
3:6
3:6
3:6
3:6
Skin
3 Stage III
3 Stage III
Intact
Stage II
Wt (5’8”)
-
89
95
89
BMI
-
13.5%
14.4%
13.5%
Infection
Pneumonia
-
-
Cough,
congestion
O2
-
-
-
-
Mrs. Doe
Clinical Documentation
Nursing:
 dementia AEB ↓ ability to
verbalize…speech
garbled…inappropriate
responses…requires frequent cues to
eat…finger foods only…takes one hour
to eat meal…loss of six lbs in past
month…facility RN indicated pt having 
congestion, coughing…afebrile
Mrs. Doe
Clinical Documentation
Social Work:
Met w/ family to discuss their financial
concerns…application for Medicaid
initiated since funds are more
limited…spent time with pt…unable to
verbalize anything other than repeating
“Help me! Help me!” Appears to have lost
weight AEB baggy clothes, unable to keep
dentures in her mouth…facility nurse
reports she is eating less…coughing
Mrs. Doe
Clinical Documentation
Volunteer:
Spent time today with Mrs.
Doe…unable to communicate except
to repeat the words “Help me! Help
me!”…assisted her with her lunch- she
chewed food but did not
swallow…appears to have lost weight
Recert Case Example
2. Mr. Adams:
• DX: Debility
• Age: 92
• Residence: Daughter’s home
• PCG: Daughter; granddaughter
• PTA: Rapid decline in past 6 months; recent
hospitalization for pneumonia; refusing food;
↓25 lbs; 155#; BMI=24.3% (normal weight)
• Comorbids: CAD, COPD, Dementia
• Secondary Conditions: None
RECERTIFICATION: Mr. Adams
DATA
PTA
SOC
1ST
RECERT
2nd
RECERT
KPS / PPS
-
40%
50%
40%
FAST
-
6e
7a
7a
NYHA
-
N/A
N/A
N/A
ADLs
Indep
2:6
3:6
4:6
Skin
Intact
Stage III
Stage II
Intact
Wt (5’8”)
-
115
115
125
BMI
-
17.5%
17.5%
19%
Infection
Pneumonia
-
-
Cough,
congestion
O2
-
-
-
-
Mr. Adams
Clinical Documentation
Nursing:
Mr. Adams spending 20 hours/day in
bed; unable to walk w/o assistance of
two; ambulates only 5-10 ft compared
to 25 feet last month; HA feeding pt his
meals resulting in  in wt by 10 lbs;  in
confusion; speech very limited; mostly
unintelligible; cough; congested; temp
101 degrees; will discuss findings with
MD
Mr. Adams
Clinical Documentation
Chaplain:
Visited w/ Mr. Adams; appears more
tired today; fell asleep during my 10
min visit; his eyes focused on me but
he did not attempt to talk; skin warm to
touch; coughing; I called his nurse to
discuss my findings; prayed for Mr.
Adams before leaving.
Mr. Adams
Clinical Documentation
Social Worker:
Visited with Mr. Adams today…he was
nonresponsive…appeared to be
weaker…slept during my visit; his
daughter was visiting…she voiced
surprise at the change in him since last
week…we discussed what to expect as
his condition continued to deteriorate.
Recert Case Examples
3. Mr. Smith:
• DX: CAD
• Age: 75
• Residence: ALF
• PCG: Facility; wife
• PTA: Optimally treated with Lisinopril, Lasix,
and Digoxin; C/O feeling tired all the time;
“winded”, able to ambulate 10 feet with 5 min
recovery time; ↓10 lbs; 165#; BMI=23.7%
• Comorbids: CAD, COPD, Dementia
• Secondary Conditions: None
RECERTIFICATION: Mr. Smith
DX: Heart disease
DATA
PTA
SOC
1ST
RECERT
2nd
RECERT
KPS / PPS
-
40%
50%
40%
FAST
-
6a
6a
6b
NYHA
-
IV
IV
IV
ADLs
Indep
4:6
5:6
5:6
Skin
Intact
intact
intact
Stage I
Wt (5’10”)
175
165
160
158
BMI
-
25.1%
23.0%
22.7%
Infection
Pneumonia
-
-
Cough,
congestion
O2
-
w/activity
Con’t
Con’t
Mr. Smith
Clinical Documentation
Nursing:
Pt in bed on arrival; says he is spending most
of the time in bed; dyspneic at rest with resp
rate of 24 breaths/min; O2 sat is 90% w/ O2
at 4L via NC; drops to 85% w/o O2 for 5 min;
febrile with temp 101; lungs congested with
wheezes and rhonchi throughout; CXR
ordered; started on Levaquin; had difficulty
talking d/t dyspnea; c/o feeling weak, tired; no
appetite; HA  to 5/wk
Mr. Smith
Clinical Documentation
Social Worker:
It was difficult to converse with Mr.
Smith today. He was more SOB and
had to stop frequently to catch his
breath. Sitting forward in bed leaning
over the BST; O2 on continuously;
using his inhaler more frequently than
usual. Called the nurse to report my
findings. She plans to visit him today.
Mr. Smith
Clinical Documentation
Chaplain:
Visited Mr. Smith today but he refused the
visit, c/o too tired and SOB. He appeared very
SOB and uncomfortable. His wife told me the
nurse is on her way. This is the second visit in
two weeks in which Mr. Smith appears more
short of breath. His wife says he is spending
most of his time sitting up in bed or the
recliner next to his bed. She reported that he
is no longer able to ambulate to the kitchen
for his dinner.
Compassion, Care and Eligibility
• Remember… hospice has an obligation to
admit, certify and recertify only those patients
who meet the guidelines set forth by Medicare (if
Medicare is the payer).
• Patients who do not meet the guidelines (e.g.
lack a 6 month prognosis) may have the same
need as those who do.
• Even though you may want to provide services
to these patients, you cannot base eligibility on
patient “need” or on the amount of care
provided.
QUESTIONS