Determining Terminal Status (L34538)
Coverage Indications, Limitations, and/or Medical Necessity
Medicare coverage of hospice depends on a physician’s certification that an individual’s prognosis is a life expectancy of six months or less if the terminal illness runs its normal course. This policy describes guidelines to be used by Home Health & Hospice (HH&H) MAC in reviewing hospice claims and by hospice providers to determine eligibility of beneficiaries for hospice benefits. Although guidelines applicable to certain disease categories are included, this policy is applicable to all hospice patients. It is intended to be used 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
Clinical variables with general applicability without regard to diagnosis, as well as clinical variables applicable to a limited number of specific diagnoses, are provided. Patients who meet the guidelines established herein are expected to have a life expectancy of six months or less if the terminal illness runs its normal course. Some patients may not meet these guidelines, yet still have a life expectancy of 6 months or less. Coverage for these patients may be approved if documentation of clinical factors supporting a less than 6-month life expectancy not included in these guidelines is provided.
If a patient improves or stabilizes sufficiently over time while in hospice such that he/she no longer has a prognosis of six months or less from the most recent recertification evaluation or definitive interim evaluation, that patient should be considered for discharge from the Medicare hospice benefit. Such patients can be re-enrolled for a new benefit period when a decline in their clinical status is such that their life expectancy is again six months or less. On the other hand, patients in the terminal stage of their illness who originally qualify for the Medicare hospice benefit but stabilize or improve while receiving hospice care, yet have a reasonable expectation of continued decline for a life expectancy of less than six months, remain eligible for hospice care.
A patient will be considered to have a life expectancy of six months or less if he/she meets the non-disease specific decline in clinical status guidelines described in Part I. Alternatively, the baseline non-disease specific guidelines described in Part II plus the applicable disease specific guidelines listed in the appendix will establish the necessary expectancy.
Part I. Decline in clinical status guidelines
Patients will be considered to have a life expectancy of six months or less if there is documented evidence of decline in clinical status based on the guidelines listed below. Since determination of decline presumes assessment of the patient’s status over time, it is essential that both baseline and follow-up determinations be reported where appropriate. Baseline data may be established on admission to hospice or by using existing information from records. Other clinical variables not on this list may support a six-month or less life expectancy. These should be documented in the clinical record.
These changes in clinical variables apply to patients whose decline is not considered to be reversible. They are listed in order of their likelihood to predict poor survival, the most predictive first and the least predictive last. No specific number of variables must be met, but fewer of those listed first (more predictive) and more of those listed last (least predictive) would be expected to predict longevity of six months or less.
1. Progression of disease as documented by worsening clinical status, symptoms, signs and laboratory results
- A. Clinical Status
- 1) Recurrent or intractable infections such as pneumonia, sepsis or upper urinary tract.
- 2) Progressive inanition as documented by:
- a) Weight loss not due to reversible causes such as depression or use of diuretics
- b) Decreasing anthropomorphic measurements (mid-arm circumference, abdominal girth), not due to reversible causes such as depression or use of diuretics
- c) Decreasing serum albumin or cholesterol
- 3) Dysphagia leading to recurrent aspiration and/or inadequate oral intake documented by decreasing food portion consumption.
- B. Symptoms
- 1) Dyspnea with increasing respiratory rate
- 2) Cough, intractable
- 3) Nausea/vomiting poorly responsive to treatment
- 4) Diarrhea, intractable
- 5) Pain requiring increasing doses of major analgesics more than briefly.
- C. Signs
- 1) Decline in systolic blood pressure to below 90 or progressive postural hypotension
- 2) Ascites
- 3) Venous, arterial or lymphatic obstruction due to local progression or metastatic disease
- 4) Edema
- 5) Pleural / pericardial effusion
- 6) Weakness
- 7) Change in level of consciousness
- D. Laboratory (When available. Lab testing is not required to establish hospice eligibility.)
- 1) Increasing pCO2 or decreasing pO2 or decreasing SaO2
- 2) Increasing calcium, creatinine or liver function studies
- 3) Increasing tumor markers (e.g. CEA, PSA)
- 4) Progressively decreasing or increasing serum sodium or increasing serum potassium
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
Part II. Non-disease specific baseline guidelines (both of these should be met)
1. Physiologic impairment of functional status as demonstrated by: Karnofsky Performance Status (KPS) or Palliative Performance Score (PPS) <70%. Note that two of the disease specific guidelines (HIV Disease, Stroke and Coma) establish a lower qualifying KPS or PPS.
2. Dependence on assistance for two or more activities of daily living (ADLs)
- A. Feeding
- B. Ambulation
- C. Continence
- D. Transfer
- E. Bathing
- F. Dressing
See appendix for disease specific guidelines to be used with these (Part II) baseline guidelines. The baseline guidelines do not independently qualify a patient for hospice coverage.
Note: The word “should” in the disease specific guidelines means that on medical review the guideline so identified will be given great weight in making a coverage determination. It does not mean, however, that meeting the guideline is obligatory.
Part III. Co-morbidities
Although not the primary hospice diagnosis, the presence of disease 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.
- A. Chronic obstructive pulmonary disease
- B. Congestive heart failure
- C. Ischemic heart disease
- D. Diabetes mellitus
- E. Neurologic disease (CVA, ALS, MS, Parkinson’s)
- F. Renal failure
- G. Liver Disease
- H. Neoplasia
- I. Acquired immune deficiency syndrome
- J. Dementia
Medical review of records of hospice patients that do not document that patients meet the guidelines set forth herein may result in denial of coverage unless other clinical circumstances reasonably predictive of a life expectancy of six months or less are provided.
The condition of some patients receiving hospice care may stabilize or improve during or due to that care, with the expectation that the stabilization or improvement will not be brief and temporary. In such circumstances, if the patient’s condition changes such that he or she no longer has a prognosis of life expectancy of six months or less, and that improvement can be expected to continue outside the hospice setting, then that patient should be discharged from hospice.
On the other hand, patients in the terminal stage of their illness who originally qualify for the Medicare hospice benefit but stabilize or improve while receiving hospice care, yet have a reasonable expectation of continued decline for a life expectancy of less than six months, remain eligible for hospice care.