PHYSICIAN REFERENCE GUIDE FOR HOSPICE ELIGIBILITY www.regencyhospice.com Office: (850) 478-2695 Fax: (850) 478-9481
OUR MISSION The mission of Curo Health Services, and its hospice affiliates, is to honor life and offer compassion to individuals, and their families, when facing a lifelimiting illness.
TABLE OF CONTENTS 4 Introduction 5 General Eligibility Criteria 7 Dementia and Related Disorders 8 Cancer 10 Heart Disease 14 HIV/AIDS 15 Pulmonary Disease 17 Liver Disease 20 Renal Failure 22 Stroke and Coma 23 Other Neurological Disorders 25 The Karnofsky Performance Scale 26 Pallative Performance Scale (PPS) 27 Functional Assessment Staging Test 28 Reimbursement for Hospice Services 31 Our Locations
INTRODUCTION A patient is eligible for hospice services under the Medicare Hospice Benefit if the physician determines their prognosis to be six months or fewer if the disease runs its normal course. To assist with the terminal prognosis, Medicare has provided us with guidelines for determining the prognosis. These guidelines are provided as a reference only and are not the sole determining factors. Secondary and co-morbid conditions may significantly impact a patient s prognosis and should be considered when making eligibility determinations.
GENERAL ELIGIBILITY CRITERIA Terminal Prognosis: 6 months or less if the disease runs it s normal course. Election of Palliative Care vs. Curative Care Significant co-morbid conditions, the severity of which is likely to contribute to a life expectancy of 6 months or less. Decline in clinical status as evidenced by any of the following: Increase in symptoms Decline in functional status Increased hospitalizations and/or ER visits Progressive pressure ulcers Weight loss Dyspnea with O2 dependence www.regencyhospice.com 5
Decline in nutritional status Change in level of consciousness Increased weakness requiring assistance or dependence in 2 or more ADL s OUR CORE VALUE #1 Choose the right attitude, message and priority.
DEMENTIA (Due to Alzheimer s and Related Disorders) Patient must present at FAST Scale Stage 7A: Patient s ability to speak is limited to approximately 6 intelligible words or fewer in the course of an average day or an intensive interview AND requires assistance with ADL s. Supporting conditions: Aspiration Pneumonia Urinary tract infections Sepsis Dysphagia Delirium Decubitus Ulcers Impaired nutritional status Serum Albumin <2.5mg/dl with weight loss Fever recurrent after antibiotics www.regencyhospice.com 7
CANCER Disease with metastasis OR cancers with poor prognosis. Other Signs May Include: Increasing tumor mass Failure of Chemotherapy/Radiation or patient refuses aggressive therapy (Except for palliative treatment for specific signs and symptoms) Nutritional Impairment Declining functional status Multiple hospitalizations/er visits in last 6 months Presence of significant co-morbid condition(s) Medication(s) needed for symptom control and/or frequent medication changes are required. Refusing aggressive treatment
OUR CORE VALUE #2 Be accountable for all thoughts, words, and actions. www.regencyhospice.com 9
HEART DISEASE (CHF, CAD, Cardiomyopathy, Hypertensive Heart Disease) The patient has significant symptoms of recurrent congestive heart failure (CHF) at rest, and is classified as a New York Heart Association (NYHA) Class IV: Unable to carry on any physical activity without discomfort. Symptoms are present even at rest. If any physical activity is undertaken, symptoms are increased. AND The patient is already optimally treated with diuretics and vasodilators, which may include ACE inhibitors or the combination of hydralazine and nitrates. If side effects, such has allergy, hypotension, hyperkalemia or chronic
kidney disease, prohibit the use of standard therapy, this must be documented in the medical records. OR Patient is having angina pectoris at rest, resistant to standard nitrate therapy and is either not a candidate or declines invasive procedures. Other variables lending support to terminal diagnosis include: Treatment resistant symptomatic arrhythmias History of cardiac arrest or resuscitation Edema Syncope Orthopnea Diaphoresis Brain embolism of cardiac origin Documentation of ejection fraction of 20% or less. www.regencyhospice.com 11
New York Heart Association (NYHA) Functional Classification Class I II III IV Patient Symptoms No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea (shortness of breath). Slight limitation of physical activity. Comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea (shortness of breath). Marked limitation of physical activity. Comfortable at rest. Less than ordinary activity causes fatigue, palpitation, or dyspnea. Unable to carry on any physical activity without discomfort. Symptoms of heart failure at rest. If any physical activity is undertaken, discomfort increases.
WHO WE ARE Regency Hospice is an affiliate of Curo Health Services and offers compassionate Hospice Care, with clinical experience, to thousands of special patients and families in locations listed on our website.
HIV/AIDS CD4+ count is < 25 cells/mc/l OR Persistent Viral Load > 100,000 copies/ml AND one of the following: CNS Lymphoma Bacteremia Progressive multifocal leukoencephalopathy Wasting Syndrome Systemic Lymphoma Visceral Kaposi s Sarcoma Cryptosporidium infection Toxoplasmosis, unresponsive Renal failure in absence of dialysis Visceral Kaposi s sarcoma, unresponsive to treatment AND Absence of antiretroviral, chemotherapeutic and prophylactic drug therapy related specifically to the HIV disease.
PULMONARY DISEASE Severe chronic lung disease as documented by all of the following: 1. Disabling dyspnea at rest, poor or unresponsive to bronchodilators, resulting in decreased functional capacity. 2. Progression of end stage pulmonary disease, as evidenced by increased visits to the ER or hospitalizations related to pulmonary infections and/or respiratory failure. 3. Hypoxemia at rest on room air, as evidenced by po2 < or = 55mmHg; or O2 saturation < or = 88% on room air. OR Hypercapnia as evidenced by pco2 > or = 50mmHg within past 3 months Other variables lending support to terminal diagnosis include:
FEV1 after bronchodilators less than 30% of the predicted value Serial decrease of FEV1 >40ml/yr Right sided heart failure secondary to pulmonary disease (Cor pulmonale) Unintentional progressive weight loss of > 10% of body weight over past 6 months Resting tachycardia >100 bpm Steroid dependence OUR CORE VALUE #3 Embrace and drive change. Pursue growth and learning.
LIVER DISEASE End stage liver disease with BOTH: Prothrombin Time prolonged more than 5 seconds over control or INR > 1.5 AND Serum Albumin <2.5 gm/dl AND one of the following: Ascites, refractory (may require palliative paracentesis) Spontaneous bacterial peritonitis Hepatorenal Syndrome Hepatic encephalopathy, refractory Recurrent variceal bleeding despite intensive therapy Other variables lending support to the terminal diagnosis: Cirrhosis Hepatitis B and/or C
Muscle Wasting Progressive malnutrition Hepatocellular carcinoma Continued active alcoholism Depression Sleep disturbances Malnutrition Please note: Patients awaiting liver transplant who fit criteria above, may be considered for hospice, but if a donor organ is procured, the patient must be discharged from hospice. www.regencyhospice.com 18
OUR CORE VALUE #4 Demonstrate humility and servant leadership.
RENAL FAILURE Renal failure: Not seeking dialysis or is discontinuing dialysis AND Creatinine clearance < 10 cc/min (< 15 cc/min for diabetics); or < 15 cc/min (<20 cc/min for diabetics) with comorbidity of CHF OR Serum creatinine >8.0 mg/dl (>6.0 mg/dl for diabetics) OR GFR <15% Other variables lending support to the terminal diagnosis: www.regencyhospice.com 20
Potassium >7 meq/l Oliguria <400 cc/24 hours Hepatorenal Syndrome Anasarca Malignancy (other organ system) Advanced Liver, Cardiac, or Pulmonary disease(s) Sepsis Platelet count < 25,000 Disseminated intravascular coagulation Gastrointestinal bleeding Albumin <3.5 gm/dl OUR CORE VALUE #5 Select great people, treat them with respect, help them, and communicate effectively.
STROKE / COMA Karnofsky Performance Status (KPS) or Palliative Performance Scales (PPS) < or = to 40% (requires assistance with ADL s, primarily bedfast) AND Poor nutritional status with inability to maintain sufficient fluid and decreased caloric intake as evidenced by: Weight loss >10% in past 6 months or 7.5%in past 3 months Serum Albumin <2.5 gm/dl Dysphagia severe enough to prevent patient from receiving necessary nutrition to sustain life. Patient who declines artificial nutrition and hydration or is declining despite preexisting artificial nutrition and hydration. www.regencyhospice.com 22
OTHER NEUROLOGICAL DISORDERS (Parkinson s, Multiple Sclerosis, Huntington s, Myesthenia Gravis, ALS) Key Indicators for Hospice Eligibility: Decrease in functional status Significant dyspnea at rest Inability to maintain hydration or caloric intake Documented weight loss 10% or > of total body weight Serum Albumin <2.5 gm/dl Aspiration Pneumonia Dysphagia Decubitus ulcers Dependence for 2 or > ADL s Patient declines artificial ventilation Additional supporting documentation related to balance, strength, endurance, antibiotic use, tube feedings, bowel/bladder function, and/or co-morbidities that support prognosis
OUR CORE VALUE #6 We are here for our patients and each other. Be passionate about what we do. Be innovative and efficient in everything we do.
The Karnofsky Performance Scale 100 Normal; no complaints; no evidence of disease Able to carry on normal activity and to work; no special care needed. Unable to work; able to live at home and care for most personal needs; varying amount of assistance needed. Unable to care for self; requires equivalent institutional hospital care; disease may be progressing rapidly. 90 Able to carry on normal activity; minor signs or symptoms of disease 80 Normal activity with effort; some signs or symptoms of disease 70 Cares for self; unable to carry on normal activity or do work 60 Requires occasional assistance, but is able to care for most personal needs 50 Requires considerable assistance and frequent medical care 40 Disabled; requires special care and assistance 30 Severely disabled; hospitalization indicated although death not imminent 20 Very sick; hospitalization necessary; requires active support treatment 10 Moribund; fatal processes progressing rapidly 0 Dead
Pallative Performance Scale (PPS) PPS LEVEL AMBULATION ACTIVITY & EVIDENCE OF DISEASE SELF-CARE INTAKE CONSCIOUS LEVEL 100% Full Normal activity & work No evidence of disease FULL Normal Full 90% Full Normal activity & work Some evidence of disease FULL Normal Full 80% Full Normal activity with Effort Some evidence of disease FULL Normal or Reduced Full 70% Reduced Unable Normal Job/Work Significant disease FULL Normal or Reduced Full 60% Reduced Unable hobby/house work Significant disease Occasional assistance necessary Normal or Reduced Full or Confusion 50% Mainly Sit/Lie Unable to do any work Extensive disease Considerable assistance required Normal or Reduced Full or Confusion 40% Mainly in Bed Unable to do most activity Extensive disease Mainly assistance Normal or Reduced Full or Drowsy +/ Confusion 30% Totally Bed Bound Unable to do any activity Extensive disease Total Care Normal or Reduced Full or Drowsy +/ Confusion 20% Totally Bed Bound Unable to do any activity Extensive disease Total Care Minimal to sips Full or Drowsy +/ Confusion 10% Totally Bed Bound Unable to do any activity Extensive disease Total Care Mouth care only Drowsy or Coma +/ Confusion 0% Death - - - -
Functional Assessment Staging Test STAGE STAGE NAME CHARACTERISTIC EXPECTED UNTREATED AD DURATION (MONTHS) MENTAL AGE (YEARS) MMSE (SCORE) 1 Normal Aging No deficits whatsoever - ADULT 29-30 2 Possible Mild Cognitive Impairment Subjective functional deficit - - 28-29 3 Mild Cognitive Impairment Objective functional deficit interferes with a person s most complex tasks 84 12+ 24-28 4 Mild Dementia IADLs become affected, such as bill paying, cooking, cleaning, traveling 24 8-12 19-20 5 Moderate Dementia Needs help selecting proper attire 18 5-7 15 6A Moderately Severe Dementia Needs help putting on clothes 4.8 5 9 6B Moderately Severe Dementia Needs help bathing 4.8 4 8 6C Moderately Severe Dementia Needs help toileting 4.8 4 5 6D Moderately Severe Dementia Urinary incontinence 3.6 3-4 3 6E Moderately Severe Dementia Fecal incontinence 9.6 2-3 1 7A Severe Dementia Speaks 5-6 words during day 12 1.25 0 7B Severe Dementia Speaks only 1 word clearly 18 1 0 7C Severe Dementia Can no longer walk 12 1 0 7D Severe Dementia Can no longer sit up 12 0.5-0.8 0 7E Severe Dementia Can no longer smile 18 0.2-0.4 0 7F Severe Dementia Can no longer hold up head 12+ 0-0.2 0
REIMBURSEMENT FOR HOSPICE SERVICES If you are a physician, not contracted with our hospice, you can still follow your patient as the Attending Physician while on hospice services. 1. Compensation for any professional service. Bill directly to Medicare with the following modifier codes: GV Services provided by hospice attending MD and related to hospice diagnosis GW Services provided by hospice attending MD and not related to hospice diagnosis GV or GW + Q5 Adding Q5 to appropriate modifier covers physician in same group as www.regencyhospice.com 28
attending to bill for services 2. Compensation for Hospice Care Plan Oversight. Receive Reimbursement for the work you are already doing. According to The Medicare Benefit Policy Manual, Physicians or Nurse Practitioners as the Attending Physician, may be reimbursed for time spent overseeing the treatment and care of their patients. Documentation must be completed and submitted for reimbursement by the physician or nurse practitioner. GO182- Code used for services include: Review/treatment plans and patient status reports Phone calls with other healthcare professionals (not employed in same practice) Pharmacy phone/face to face discussion pertaining to Pharmaceutical therapies Medical decision making and
adjustments of medical therapy (wound care, medications) Adding new information to the care plan To receive reimbursement for CPO, the physician must spend at least 30 minutes rendering care plan oversight for each hospice patient in a calendar month. Please note: This code may not apply to Rural Health Clinics as designated by state or federal law. OUR CORE VALUE #7 Celebrate small successes on our journey to greater success.
OUR LOCATIONS Regency is available 24/7, 365 days/year For Hospice referrals or any questions, please contact any of the local Regency Teams: Fort Walton Beach, FL 11 Racetrack Road, Suite G Fort Walton Beach, FL 32547 M: 850.226.4166 F: 850.226.6932 Pensacola, FL 50 Beverly Parkway, Suite200 Pensacola, FL 32550 M: 850.478.2695 F: 850.478.9481 DeFuniak Springs, FL 1045 C US Hwy 331 South DeFuniak Springs, FL 32435 M: 850.951.9849 F: 850.951.9850
www.regencyhospice.com (850) 478-2695 Fax: (850) 478-9481