Hospice Eligibility. Jeanette S. Ross MD, AGSF, FAAHPM

Hospice Eligibility Jeanette S. Ross MD, AGSF, FAAHPM

Objectives To define the Medicare Hospice benefit an describe the basic services To identify the medical criteria for Hospice eligibility as it applies to common terminal diagnoses To describe the difference between Medicare Hospice Eligibility Requirements and Hospice Local Coverage Determination (LCD) for Determining Terminal Status To exemplify a clinical documentation that supports medical necessity for a patient to be admitted to hospice

Medicare Hospice Eligibility Requirements Entitled to Medicare Part A or have other insurance Certified as being terminally ill and documented by two physicians Patient agrees to forgo Medicare coverage for curative treatment of their terminal illness Care is through a Medicare-approved hospice program Centers for Medicare & Medicaid services, HHS 418.22 Certification of terminal illness. https://www.gpo.gov/fdsys/pkg/cfr-2011-title42-vol3/pdf/cfr-2011-title42-vol3-sec418-22.pdf

What Hospice Offers Hospice Comprehensive, total care Medications related to terminal illness covered Staff on call 24 hours Support for family Bereavement support Physician care not covered (except Medical Director) Prognosis-based eligibility Standard Home Care Task-oriented care Medications not covered Scheduled visits Patient care only No bereavement support Physician care not covered Home-bound, skilled care need

Hospice Levels of Care Routine Home Care (RHC): Core services of hospice interdisciplinary team provided at patient s home (place of residence) Continuous Home Care (CHC): intended to support patient and their caregivers through brief periods of crisis. Inpatient Respite Care (IRC): short term care to provide relief to family/ primary caregiver. General Inpatient Care (GIP): care provided in acute hospital or other setting with intensive nursing & other support outside of the home. For management of uncontrolled distressing physical symptoms or psychosocial problems

Hospice Benefit Periods Duration of hospice care coverage Election periods: An initial 90-day period; A subsequent 90-day period; or An unlimited number of subsequent 60-day periods

Hospice Face-To-Face (FTF) Encounter Must include documentation that a hospice physician or a hospice nurse practitioner had a FTF encounter with the patient Used to gather clinical findings to determine continued eligibility for hospice care The FTF must occur within 30 days calendar prior to the start of the *3rd benefit period and every subsequent recertification period

Scales for Documentation Function: KPS, PPS, ECOG,ADLs, IADLs, Morse Fall scale Nutrition: height, weight, BMI, meal %, cal estimates Mental Status: Ramsay sedation scale, FAST, MMSE Cardiac:NYHA, BNP, ECHO Respiratory: Functional dyspnea scale Skin: skin turgor, edema, capillary refill, Braden scale, pressure ulcer stages Symptoms: pain scale, PAINAD scale, response to treatement

Karnofsky Performance Scale Able to carry on normal activity and to work No special care needed. Unable to work; able to live at home and care for personal needs; varying amount of assistance needed. Unable to care for self; Requires equivalent of institutional or hospital care diseases may be progressing rapidly. % Description 100% Normal no complaints; no evidence of disease. 90% Able to carry on normal activity; Minor signs or symptoms of disease. 80% Normal activity with efforts; some signs or symptoms of disease. 70% 60% 50% Cares for self; unable to carry on normal most activity or to do active work. Requires occasional assistance, but is able to care for most of his personal needs. Requires considerable assistance and frequent medical care. 40% Disabled; requires special care and assistance.; 30% 20% Severely disabled; hospital admission is indicated although death not imminent. Very sick; hospital admission necessary; Active supportive treatment necessary. 10% Moribund; fatal processes progressing rapidly. 0% Dead

Medicare Hospice Eligibility An individual must be entitled to Medicare A and be certified as being terminally ill Certified with a life expectancy of 6 months or less if the illness runs its normal course based on the clinical judgment of the hospice medical director or physician member of the interdisciplinary group (IDG) and the individual s attending physician, if he/she has one Local Coverage Determination (LCDs) Guidelines to identify any Medicare beneficiary whose current clinical status and anticipated progression of disease is more likely than not to result in a life expectancy of six months or less Terminal Diagnosis/Prognosis The diagnosis (ICD Code) that the certifying hospice physician determines to be the most contributory to the patient s terminal condition. Hospices are to report this principal diagnosis (ICD Code) on their claims form CMS expects all of a patient s coexisting or additional diagnoses (ICD Codes) related to the terminal illness or related conditions should be reported in the additional coding fields on the hospice claim (i.e. secondary diagnoses)

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 & 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 face to face encounter

Local Coverage Determination (LCDs) CGS and NGS (1 LCD with Multiple Indicators Non-disease specific decline in clinical status ALS Cancer Dementia due to Alzheimer s disease Heart disease HIV disease Liver disease Pulmonary disease Renal disease Stroke and Coma Local Coverage Determination (LCDs) Palmetto Adult failure to thrive syndrome Alzheimer s disease Cardiopulmonary conditions HIV disease Liver disease Neurological conditions Renal care Terminal Diagnosis The diagnosis (ICD Code) that the certifying hospice physician determines to be the most contributory to the patient s terminal condition. Do not list Debility or Adult Failure to Thrive as the primary terminal diagnosis

Hospice Principal Diagnosis It s the condition that mainly contributes to the person s terminal prognosis Non-specific diagnoses such as Debility or Adult Failure to Thrive (AFTT) may no longer be listed as a principal terminal diagnosis Debility and AFTT can and should be listed as secondary (related) conditions to support prognosis if indicated

Common Hospice Diagnoses Cancer End-stage Heart Disease End-Stage Lung Disease End-Stage Renal Disease End-Stage Liver Disease Stroke/coma HIV Neurological Disease Parkinson's, Alzheimer's General Decline in Health Status

Cancer Patient meets ALL of the following: 1.Clinical findings of malignancy with widespread, aggressive or progressive disease as evidenced by increasing symptoms worsening lab values and/or evidence of metastatic disease 2.Palliative performance Scale (PPS) 70% 3.Refuses further life-prolonging therapy OR continues to decline in spite of definitive therapy Supporting documentation includes: Hypercalcemia > 12 Cachexia or weight loss of 5% in past 3 months Recurrent disease after surgery/radiation/chemotherapy Signs and symptoms of advanced disease (e.g. nausea, requirement for transfusions, malignant ascites or pleural effusion, etc.)

Heart Disease The patient has 1 and either 2 or 3. 1. CHF with NYHA Class IV* symptoms & both: Significant symptoms at rest Inability to carry out even minimal physical activity without dyspnea or angina 2. Patient is optimally treated (ie diuretics, vasodilators, ACEI, or hydralazine and nitrates) 3. The patient has angina pectoris at rest, resistant to standard nitrate therapy, and is either not a candidate for/or has declined invasive procedures. Supporting documentation includes: EF 20%, Treatment resistant symptomatic dysrhythmias h/o cardiac related syncope, CVA 2/2 cardiac embolism H/o cardiac resuscitation, concomitant HIV disease

Liver Disease The patient has both 1 and 2. 1. End stage liver disease as demonstrated by A or B, & C: A. PT> 5 sec OR B. INR > 1.5 AND C. Serum albumin <2.5 gm / dl AND 2. One or more of the following conditions: Refractory Ascites, h/o spontaneous bacterial peritonitis, Hepatorenal syndrome, refractory hepatic encephalopathy, h/o recurrent variceal bleeding Supporting Documents includes: Progressive malnutrition, Muscle wasting with decreased strength. Ongoing alcoholism (> 80 gm ethanol/day), Hepatocellular CA HBsAg positive, Hep. C refractory to treatment

Pulmonary Disease Severe chronic lung disease as documented by 1, 2, and 3. 1. The patient has all of the following: Disabling dyspnea at rest Little of no response to bronchodilators Decreased functional capacity (e.g. bed to chair existence, fatigue and cough) AND 2. Progression of disease as evidenced by a recent h/o increasing office, home, or ED visits and/or hospitalizations for pulmonary infection and/or respiratory failure. AND 3. Documentation within the past 3 months 1: Hypoxemia at rest on room air (p02 < 55 mmhg by ABG) O 2 sat < 88% Hypercapnia evidenced by pc02 > 50 mmhg Supporting documentation includes: Cor Pulmonale and right heart failure Unintentional progressive weight loss

Renal Disease The patient has 1, 2, and 3. 1. The pt is not seeking dialysis or renal transplant AND 2. Creatinine clearance* is < 10 cc/min (<15 for diabetics) AND 3. Serum creatinine > 8.0 mg/dl (> 6.0 mg/dl for diabetics) Supporting documentation for chronic renal failure includes: Uremia, Oliguria (urine output < 400 cc in 24 hours), Intractable hyperkalemia (> 7.0), Uremic pericarditis, Hepatorenal syndrome, Intractable fluid overload. Supporting documentation for acute renal failure includes: Mechanical ventilation, Malignancy (other organ system) Chronic lung disease, Advanced cardiac disease, Advanced liver disease

Neurologic Disease The patient must meet at least one of the following criteria (1 or 2A or 2B): 1. Critically impaired breathing capacity, with all: Dyspnea at rest, Vital capacity < 30%, Need O 2 at rest, patient refuses artificial ventilation OR 2. Rapid disease progression with either A or B below: Progression from : independent ambulation to wheelchair or bed-bound status normal to barely intelligible or unintelligible speech normal to pureed diet independence in most ADLs to needing major assistance in all ADLs AND A. Critical nutritional impairment demonstrated by all of the following in the preceding 12 months: Oral intake of nutrients and fluids insufficient to sustain life Continuing weight loss Dehydration or hypovolemia Absence of artificial feeding methods OR B. Life-threatening complications in the past 12 months as demonstrated by 1: Recurrent aspiration pneumonia, Pyelonephritis, Sepsis, Recurrent fever, Stage 3 or 4 pressure ulcer(s)

Stroke Or Coma The patient has both 1 and 2. 1. Poor functional status PPS* 40% AND 2. Poor nutritional status with inability to maintain sufficient fluid and calorie intake with 1 of the following: 10% weight loss in past 6 months 7.5% weight loss in past 3 months Serum albumin <2.5 gm/dl Current history of pulmonary aspiration without effective response to speech therapy interventions to improve dysphagia and decrease aspiration events Supporting documentation includes: Coma (any etiology) with 3 of the following on the 3 rd day of coma: Abnormal brain stem response Absent verbal responses Absent withdrawal response to pain Serum creatinine > 1.5 gm/dl

Dementia The patient has both 1 and 2: 1. Stage 7C or beyond according to the FAST Scale AND 2. One or more of the following conditions in the 12 months: Aspiration pneumonia Pyelonephritis Septicemia Multiple pressure ulcers ( stage 3-4) Recurrent Fever Other significant condition that suggests a limited prognosis Inability to maintain sufficient fluid and calorie intake in the past 6 months ( 10% weight loss or albumin < 2.5 gm/dl)

Functional Assessment Scale (FAST) for Alzheimer s Type Dementia 1 No difficulty either subjectively or objectively 2 Complains of forgetting location of objects. Subjective work difficulties. 3 Decreased job functioning evident to co-workers. Difficulty in traveling to new locations. Decreased organizational capacity. * 4 Decreased ability to perform complex task, (e.g., planning dinner for guests, handling personal finances e.g. forgetting to pay bills, etc.) 5 Requires assistance in choosing proper clothing to wear for the day, season or occasion, (e.g. pt may wear the same clothing repeatedly, unless supervised.* 6 Occasionally or more frequently over the past weeks. * for the following A) Improperly putting on clothes without assistance or cueing. B) Unable to bathe properly ( not able to choose proper water temp) C) Inability to handle mechanics of toileting (e.g., forget to flush the toilet, does not wipe properly or properly dispose of toilet tissue) D) Urinary incontinence E) Fecal incontinence 7 A) Ability to speak limited to approximately 6 intelligible different words in the course of an average day or in the course of an intensive interview. B) Speech ability is limited to the use of a single intelligible word in an average day or in the course of an intensive interview C) Ambulatory ability is lost (cannot walk without personal assistance.) D) Cannot sit up without assistance (e.g., the individual will fall over if there are not lateral rests [arms] on the chair.) E) Loss of ability to smile. F) Loss of ability to hold up head independently. *Scored primarily on information obtained from a knowledgeable informant.

Others Debility An unspecified syndrome characterized by unexplained weight loss, malnutrition, functional decline, multiple chronic conditions contributing to the terminal progression, and increasing frequency of outpatient visits, emergency department visits and/ or hospitalizations Multiple comorbid conditions Individually, may not deem the individual to be terminally ill Collective presence contributes to the terminal status of the individual

Comorbidities Documenting other significant existing diseases Document the severity and progression of these diseases Supporting evidence for 6 month prognosis: Additional organ systems involved Diseases that affect prognosis Severity more important than the amount of comorbidities

Ineligibility Decision of IDG, attending and medical director Patient must be discharged when ineligibility is determined, not end of certification 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

Relatedness (simplified version) Condition related to terminal prognosis Condition unrelated to terminal prognosis Reasonable and necessary for palliation and management Hospice Pays (for medication on hospice formulary) Paid by Prior Payor Not reasonable and necessary for palliation and management Discuss Discontinuing (if not harmful patient may purchase)

Relatedness Identify the PRINCIPAL (TERMINAL) HOSPICE DIAGNOSIS* Are there other diagnoses caused by or exacerbated by the PRINCIPAL HOSPICE DIAGNOSIS?* YES No Are there additional DIAGNOSES or SYMPTOMS that contribute to the 6 month or less prognosis? No YES RELATED The physician narrative statement and the clinical record is the appropriate documentation location for the certifying physician to reference the principal hospice diagnosis,* related diagnoses, patient prognosis, and eligibility. Are there additional DIAGNOSES, CONDITIONS, or SYMPTOMS caused or exacerbated by treatment of the RELATED CONDITIONS? YES No NOTE: National Hospice and Palliative Care Organization, The December decision about 2014, relatedness Version 1.0 is determined by the hospice physician and is individualized based on the patient s clinical

Relatedness The hospice plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. [Federal Register March 10, 2014] We expect that Medicare hospice providers will continue to provide all of the medications that are reasonable and necessary for the palliation and management of a beneficiary s terminal illness and related conditions. [Federal Register July 18, 2014]

Relatedness For prescription drugs to be covered under Part D when the enrollee has elected hospice, the drug must be for treatment of a condition that is completely unrelated to the terminal illness or related conditions; in other words, the drug is unrelated to the terminal prognosis of the individual. [Federal Register March 10, 2014]

Relatedness Medications would not be covered under the Medicare hospice benefit, if they are determined not to be reasonable and necessary for the palliation of pain and/or symptom management by the hospice interdisciplinary group, after discussions with the hospice patient and family. If a beneficiary still chooses to have these medications filled through his or her pharmacy, the costs of these medications would then become a beneficiary liability for payment and not covered by Part D. [Federal Register July 18, 2014]

Group Case Review An 85 year old patient with Alzheimer s disease FAST 6E, CHF NHYA Stage III. The patient has decreased oral intake (10% of meals), malnutrition (Albumin of 2.5), weight loss (10% of body weight over last year), BMI of 18.6, all despite 1:1 feeding assistance. The patient also has decreasing functional status (PPS was 60% six months ago currently 30%), and has progressed from using a walker to chair/bedbound status in less than six months, requires a 1 person transfer. Stage III pressure ulcer despite optimal wound prevention and treatment. This patient was determined to be terminally ill with a prognosis of less than 6 months by the certifying physicians.

Group Discussion Question Is this patient Medicare Hospice Eligible? A. Yes B. No

Group Discussion Answer Is this patient Medicare Hospice Eligible? A. Yes B. No Hospice and attending physicians have certified him with a prognosis of less than 6 months

Group Discussion Question Which Medicare LCD/Indicator could you use to support documentation of a prognosis of less than 6 months for CGS/NGS? A. Dementia due to Alzheimer s Disease B. Non-Disease Specific Decline In Clinical Status C. Heart Disease

Group Discussion Answer Which Medicare LCD/Indicator could you use to support documentation of a prognosis of less than 6 months for CGS/NGS? A. Dementia due to Alzheimer s Disease B. Non-Disease Specific Decline In Clinical Status C. Heart Disease

Non-Disease Specific Decline In Clinical Status LCD Progressive exhaustion caused by lack of nourishment as documented by: Weight loss not due to reversible causes such as depression or use of diuretics Decreasing serum albumen or cholesterol Inadequate oral intake documented by decreasing food portion consumption Worsening Signs - Weakness Decline in Palliative Performance Score (PPS) from <70% due to Progression of Disease Progression to Dependence on Assistance for Two or More Activities of Daily Living (ADLs): Feeding, Ambulation, Continence, Transfer, Bathing, Dressing Progressive Stage 3-4 Pressure Ulcers in Spite of Optimal Care Patient Weight loss (10% of body weight over last year), BMI of 18.6, all despite 1:1 feeding assistance. Malnutrition (Albumin of 2.5) Decreased oral intake (10% of meals) The patient also has decreasing functional status (PPS was 60% six months ago currently 30%) Progressed from using a walker to chair/bedbound status in less than six months, requires a 1 person transfer. Stage III pressure ulcer despite optimal wound prevention and treatment.

Group Discussion Question Which Medicare LCD/Indicator could you use to support documentation of a prognosis of less than 6 months for Palmetto? A. Adult Failure to Thrive Syndrome B. Alzheimer s Disease and related disorders C. Cardiopulmonary conditions

Adult Failure to Thrive Syndrome LCD Patient (BMI) will be below 22 kg/m 2 and that the patient is either declining enteral/parenteral nutritional support or has not responded to such nutritional support, despite an adequate caloric intake BMI of 18.6 despite 1:1 feeding assistance PPS was 60% six months ago currently 30% Palliative Performance Scale value less than or equal to 40%. BMI and level of disability should be determined using measurements/observations made within six months (180 days) of the most recent certification/recertification date.

Group Discussion Question What is your primary diagnosis? A. Adult Failure to Thrive B. Alzheimer s Disease C. Congestive Heart Failure

Group Discussion Answer What is your primary diagnosis? A. Adult Failure to Thrive B. Alzheimer s Disease C.Congestive Heart Failure

Group Discussion Answer Secondary diagnoses A. Adult Failure to Thrive, Pressure ulcer

Remember LCD Prognosis Prognostic Indicators Created in 1996 as a GUIDE to be used in conjunction with clinical judgment Never intended to be used as public policy Never validated Often ineffective at predicting prognosis Fox et al., JAMA 1999; 282:1638-1645 Schonwetter, Am JHPM 2003

Prognosis Pearls: General Indicators of Poor Prognosis Recurrent infections Weight loss [persistently low albumin (<2.5 mg/l) and/or cholesterol] Worsening functional status Increased medical utilization: hospitalizations, ER and physician visits Consider the time-frame of the decline: years, months, weeks, days? This often reflects the timeframe of remaining life-expectancy

Prognosis Pearls: General Indicators of Poor Prognosis Answer no to the surprise question: Would you be surprised if this patient died within the next year?

Factors that influence the normal course of illness Secondary and co-morbid conditions Advanced age Degree of frailty Environment of care Access to other health care professionals Baseline and trajectory of illness

Referral triggers Change in condition Hospitalization New or worsening symptoms Need for additional care Change in caregiver status or setting of care