215-322-5256General Guidelines of Hospice Diagnoses
1. Disease progression —documented by worsening clinical status, symptoms, signs and laboratory results:
A. Clinical Status: Recurrent or intractable infections such as pneumonia, sepsis or upper urinary tract. Progressive inanition documented by:
- Weight loss not due to reversible causes such as depression or use of diuretics.
- Decreasing anthropomorphic measurements (mid-arm circumference, abdominal girth), not due to reversible causes such as depression or use of diuretics.
- Decreasing serum albumen or cholesterol
- Dysphagia leading to recurrent aspiration and/or inadequate oral intake documented by decreasing food portion consumption.
- Dyspnea with increasing respiratory rate
- Cough, intractable
- Nausea/vomiting poorly responsive to treatment
- Diarrhea, intractable
- Pain requiring increasing doses of major analgesics more than briefly
- Decline in systolic blood pressure to below 90 or progressive postural hypotension
- Ascites
- Venous, arterial or lymphatic obstruction due to local progression or metastatic disease
- Edema
- Pleural/pericardial effusion
- Weakness
- Change in level of consciousness
- Increasing pCO2 or decreasing pO2 or decreasing SaO2
- Increasing calcium, creatinine or liver function studies
- Increasing tumor markers (e.g. CEA, PSA)
- Progressively decreasing or increasing serum sodium or increasing serum potassium
2. Decline in Karnofsky Performance Status (KPS) from < 70% due to progression of disease:
- 100 = normal; no complaints; no evidence of disease; able to work
- 90 = able to carry on normal activity; minor symptoms; able to work
- 80 = normal activity with effort; some symptoms; able to work
- 70 = cares for self; unable to carry on normal activity; independent; not able to work
- 60 = disabled; dependent; requires occasional assistance; cares for most needs
- 50 = moderately disabled; dependent; requires considerable assistance and frequent care
- 40 = severely disabled; dependent; requires special care and assistance
- 30 = severely disabled; hospitalized; death not imminent
- 20 = very sick; active supportive treatment needed
- 10 = moribund; fatal processes rapidly progressing
3. Dependence on assistance for two or more activities of daily living (ADLs):
- Feeding
- Ambulation
- Continence
- Transfer
- Bathing
- Dressing
4. Progressive stage 3-4 pressure ulcers despite optimal care
5. Co morbidities:
Although not the primary hospice diagnosis, the presence of the following diseases, the severity of which is likely to contribute to a life expectancy of six months or less, should be considered in determining hospice eligibility.
- Chronic obstructive pulmonary disease
- Congestive heart failure
- Ischemic heart disease
- Diabetes mellitus
- Neurologic disease (CVA, ALS, MS, Parkinson’s)
- Renal failure
- Liver Disease
- Neoplasia
- Acquired Immune Deficiency Syndrome
- Dementia
6. Recent impaired nutritional status
- Evidenced by (check all appropriate):
- unintentional, progressive weight loss of 10% over past six months
- serum albumin less than 2.5gm/dl (may be helpful prognostic indicator but should not be used by itself)
The patient must meet ALL of the following (1, 2 and 3):
1. < 40% decline in Karnofsky Performance Status:
- 40 = severely disabled; dependent; requires special care and assistance
- 30 = severely disabled; hospitalized; death not imminent
- 20 = very sick; active supportive treatment needed
- 10 = moribund; fatal processes rapidly progressing
2. Unexplained weight loss resulting in:
- Body Mass Index below 22 kg/m2
- Body Mass Index = 703 x (patient’s weight in pounds) ÷ (height in inches) 2
3. The patient is refusing enteral or parenteral nutritional support or has not responded to such nutritional support, despite adequate caloric intake.
Accepted ICD-9-CM Codes for Failure to Thrive:
- 783.7 Failure to Thrive
- 799.3 Debility Unspecified
- 799.9 Other unknown and unspecified causes of morbidity and mortality
In the absence of one or more of these findings, rapid decline or co-morbidities may also support eligibility for hospice care.
Patients are eligible for hospice care if in the physician’s clinical judgment they have a life expectancy of six months or less. These determinants are to be used as guidelines and do not take the place of a physician’s clinical judgment. Coverage for hospice care may still be appropriate for patients not meeting these determinations due to co-morbidity or rapid decline.
Karnofsky Performance Status < 50%:
- 40 = severely disabled; dependent; requires special care and assistance
- 30 = severely disabled; hospitalized; death not imminent
- 20 = very sick; active supportive treatment needed
- 10 = moribund; fatal processes rapidly progressing
- Aspiration Pneumonia
- Pyelonephritis or other upper urinary tract infection
- Speticemia
- Decubitus ulcers, multiple, stage 3-4
- Fever, recurrent after antibiotics
- Inability to maintain sufficient fluid and caloric intake with > 10% weight loss during the previous six months
- A serum albumin of < 2.5 gm/dl
- Significant dysphagia with associated aspiration measured objectively (e.g., swallowing test or a history of choking/gagging with feeding)
In the absence of one or more of these findings, rapid decline or co-morbidities may also support eligibility for hospice care.
Patients are eligible for hospice care if in the physician’s clinical judgment they have a life expectancy of six months or less. These determinants are to be used as guidelines and do not take the place of a physician’s clinical judgment. Coverage for hospice care may still be appropriate for patients not meeting these determinations due to co-morbidity or rapid decline.
1. Critically impaired breathing capacity (within the 12 months preceding hospice admission)
- Vital capacity (VC) < 30% of normal (if available)
- Dyspnea at rest
- Patient declines mechanical ventilation, with external ventilation used for comfort measures only
2. Rapid ALS progression (within the 12 months preceding hospice admission)
- from independent ambulation, to wheelchair, to bed bound status
- from normal to barely intelligible or unintelligible speech
- from normal to pureed diet
- from independence in most or all activities of daily living (ADLs) to needing major assistance in all ADL’s by caretaker
Critical nutritional impairment (within the 12 months preceding hospice admission)
- oral intake of nutrients and fluids insufficient to sustain life
- continuing weight loss
- dehydration or hypovolemia
- absence of artificial feeding methods sufficient to sustain life—not for relieving hunger
3. Patient should demonstrate rapid progression of ALS and life-threatening complications
- recurrent aspiration pneumonia (with or without tube feedings)
- upper urinary tract infection, e.g., pyelonephritis
- sepsis
- recurrent fever after antibiotic therapy
- stage 3 or 4 decubitus ulcer(s)
References: Guidelines Taken from: LCD ID Number L13653; LCD Title: Hospice – Determining Terminal Status; Contractor: Cahaba Government Benefit Administrator; Determination # HOA03-002
The patient must meet ALL of the following (1, 2 and 3):
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.
The following information will be required:
A. & nbsp; Tissue diagnosis of malignancy
B. & nbsp; Reasons why a tissue diagnosis is not available
2.Impaired performance status with a PPS (Palliative Performance Scale) ≤ 70% = at minimum is unable to work; ambulation is reduced and intake may be reduced
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 the preceding three 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.)
In the absence of one or more of these findings, rapid decline or co-morbidities may also support eligibility for hospice care.
Patients are eligible for hospice care if in the physician’s clinical judgment they have a life expectancy of six months or less. These determinants are to be used as guidelines and do not take the place of a physician’s clinical judgment. Coverage for hospice care may still be appropriate for patients not meeting these determinations due to co-morbidity or rapid decline.
The patient must meet at least one of the following criteria (1 or 2A or 2B):
1. Critical impaired breathing capacity with all of the following findings:
- Dyspnea at rest
- Dyspnea at rest
- Vital capacity less than 30%
- The requirement of supplemental oxygen at rest
- The patient declines artificial ventilation
- Progression from independent ambulation to wheelchair or bed bound status
- Progression from normal to barely intelligible or unintelligible speech
- Progression from normal to pureed diet
- Progression from independent in most or all activities of daily living (ADLs) to needing major assistance by caretaker in all ADLs
- Oral intake of nutrients and fluids insufficient to sustain life
- Continuing weight loss
- Dehydration of hypovolemia
- Absence of artificial feeding methods
- Recurrent aspiration pneumonia (with or without tube feedings)
- Upper urinary tract infection (pyelonephritis)
- Sepsis
- Recurrent fever after antibiotic therapy
- Stage 3 or 4 decubitus ulcers
In the absence of one or more of these findings, rapid decline or co-morbidities may also support eligibility for hospice care.
Patients are eligible for hospice care if in the physician’s clinical judgment they have a life expectancy of six months or less. These determinants are to be used as guidelines and do not take the place of a physician’s clinical judgment. Coverage for hospice care may still be appropriate for patients not meeting these determinations due to co-morbidity or rapid decline.
Comatose patients with any 3 of the following on day three of coma:
- abnormal brain stem response
- absent verbal response
- absent withdrawal response to pain
- serum creatinine >1.5 mg/dl.
Supportive Documentation (not required for hospice eligibility, but helpful)
Medical complications (in the context of progressive clinical decline within the previous 12 months) which support a terminal prognosis:
- aspiration pneumonia
- upper urinary tract infection (pyelonephritis)
- sepsis
- refractory stage 3-4 decubitus ulcers
- fever recurrent after antibiotics.
In the absence of one or more of these findings, rapid decline or co-morbidities may also support eligibility for hospice care.
Patients are eligible for hospice care if in the physician’s clinical judgment they have a life expectancy of six months or less. These determinants are to be used as guidelines and do not take the place of a physician’s clinical judgment. Coverage for hospice care may still be appropriate for patients not meeting these determinations due to co-morbidity or rapid decline.
References: Guidelines Taken from: LCD ID Number L13653; LCD Title: Hospice – Determining Terminal Status; Contractor: Cahaba Government Benefit Administrator; Determination # HOA03-002
1. Is the patient severely demented?…………………… The patient should be at or beyond Stage 7 of the Functional Assessment Staging Scale. (Check all that apply—must be at minimum one of the following):
- 7A- Ability to speak is limited to approximately 6 intelligible words or fewer, in the course of an average day or in the course of an intensive interview
- 7B- Speech ability is limited to the use of a single intelligible word in an average day or in the course of an intensive interview. (The person may repeat the word over and over)
- 7C- Ambulatory ability is lost (cannot walk without personal assistance)
- 7D- Cannot sit up without assistance (e.g., patient will fall over if there are not lateral rests/arms on the chair)
- 7E- Loss of the ability to smile
- 7F- Loss of the ability to hold head independently
2. Patient should show ALL of the following characteristics.
- Inability to ambulate independently (cannot walk without personal assistance)
- Unable to dress without assistance
- Unable to bathe without assistance
- Incontinence of urine and stool (intermittent or constant)
- Unable to speak or communicate meaningfully (see 7A above)
3. Has the patient had one or more of the following medical complications related to Dementia during the past 12 months?…….……………………………Patients should have had one of the following within the past 12 months.
- Aspiration Pneumonia
- Upper Urinary Tract Infection or Pyelonephritis
- Septicemia
- Decubitus Ulcer(s) multiple, Stage 3-4
- Fever, recurrent after antibiotics
- Inability or unwillingness to maintain sufficient fluid or caloric intake with a 10% weight loss during previous 6 months or serum albumen
- Patients who receive tube feedings must have documented impaired nutritional status as indicated by either:
- Unintentional progressive weight loss of greater than 10% over prior 6 month period
- Serum albumin less than 2.5 mg/dl (may be prognostic indicator, but should not be used by itself)
Numbers 1 and 2 should be present factors, from number 3 on add supporting documentation.
1. Is the patient not eligible for surgery or refusing surgery?
- Yes
- No
2. Does the patient have symptoms and signs of congestive heart failure at rest?
Patient is New York Heart Association (NYHA) Class IV as evidenced by following–Check all that apply:
- Dyspnea at rest: short winded or can’t breathe
- Dyspnea on exertion: can’t breathe with exercise
- Orthopnea: can’t breathe lying down
- Paroxysmal nocturnal dyspnea (PND): Waking up at night short of breath
- Edema: swollen ankles, feet
- Syncope
- Weaknes
- Chest pain
- Diaphoresis: sweating
- Cachexia: profound weight loss
- Jugulvenous destination (JVD)
- Neck veins distended above clavicle
- Rales: wet crackles in lungs heard on inspiration
- Gallop rhythm: S3, S4
- Gallop rhythm: S3, S4
- Liver enlargement
3. Has the physician verified the patient is on optimal diuretic & vasodilator therapy?
Diuretics—patient should be on optimal dose of one of the following. (Check all that apply):
- Furosemide (Lasix)
- Bumetanide (Bumex)
- Metolazone (Zaroxlyne, Mykrox)—may be combined with the above, but not used alone
- Ethacrynic Acid (Edecrine)
- Torsemide (Demedex)
- Nitrates (e.g., Nitropatic, Isosorbide) plus Hydralazine
- ACE (Angiotension Converting Enzyme) inhibitor:
Other:
- Apresoline
- Benzepril (Lotensin)
- Catopril (Capoten)
- Elanapril (Vasotec)
- Fosinapril (Monopril)
- Lisinopril (Prinvil, Zestril)
- Quinapril (Accupril)
- Rimipril (Altace)
4. Does the patient have an ejection fraction of less than or equal to 20%
- Yes
- No
5. The following factors are further indicators of decreased survival time. (Check all that apply):
- Symptomatic supraventricular or ventricular arrhythmias resistant to anti-arrhythmic therapy
- History of cardiac arrest and resuscitation in any setting
- Cardiogenic brain embolism; i.e., embolic CVA or cardiac origin
- Concomitant HIV disease
Factors 1 and 2 should be present, from 3 on offer supporting documentation:
1. CD4+ Count 100,000 copies/ml, plus one of the following:
- CNS Lymphoma
- Wasting—untreated or persistent despite treatment (loss of at least 10% lean body mass)
- Mycobacterium avium complex (MAC) bacteremia—untreated, unresponsive to treatment, or treatment refused
- Progressive multifocal leukoencephalopathy
- Systemic lymphoma, with advanced HIV disease and partial response to chemotherapy
- Visceral Kaposi’s sarcoma unresponsive to therapy
- Renal failure in the absence of dialysis
- Cryptosporidium infection
- Toxoplasmosis—unresponsive to therapy
2. Decreased performance status as measured by the Karnofsky Performance Status scale of < 50%
- 50 = moderately disabled; dependent; requires considerable assistance and frequent care
- 40 = severely disabled; dependent; requires special care and assistance
- 30 = severely disabled; hospitalized; death not imminent
- 20 = very sick; active supportive treatment needed
- 10 = moribund; fatal processes rapidly progressing
Supportive Documentation (not required for hospice eligibility, but helpful)
3. Chronic persistent diarrhea for one year
4. Persistent serum albumin 50 years
7. Absence of (or resistance to) effective antiretroviral, chemotherapeutic and prophylactic drug therapy related specifically to HIV disease
8. Advanced AIDS dementia complex
9. Toxoplasmosis
10. Congestive heart failure—symptomatic at rest
11. Advanced liver disease
Guidelines Taken from: LCD ID Number L13653; LCD Title: Hospice – Determining Terminal Status; Contractor: Cahaba Government Benefit Administrator; Determination # HOA03-002
The following factors have been shown to correlate with poor short-term survival in advance cirrhosis of the liver due to alcoholism, hepatitis, or uncertain causes (cryptogenic). Their effects are additive, i.e., prognosis worsens with the addition of each one and clinical judgment is vital. The following criteria should be followed and reviewed over time.
1. The patient is not a candidate for a liver transplant.
2. Laboratory indicators of severely impaired liver function should show both of the following:
- Prothrombin time prolonged more than 5 sec. over control or INR > 1.5
- Serum albumin < 2.5 gm/dl
3. Clinical indicators of end-stage liver disease (patient should show at least one of the following):
- Ascites
- Refractory to sodium restriction and diuretics; spironolactone 75-150 mg/day plus furosemide > 40 mg/day
- Patient non-compliant with treatment
- Spontaneous bacterial peritonitis (median survival 30% at one year; high mortality even when infection cured intially if liver disease is severe or accompanied by renal disease.)
- Hepatorenal syndrome (usually occurs during hospitalization; survival usually days to weeks)
- Patient has cirrhosis and ascites
- Elevated creatinine and BUN
- Oliguria 400 ml/day
- Urine sodium concentration 10mEq/l recurrent
- Recurrent variceal bleeding: patient should have re-bled despite therapy which currently includes:
- Injection sclerotherapy or band ligation, if available
- Oral beta blockers
- Transjugular intrahepatic portosystemic shunt (TIPS)
- Patient refused further therapy
- Hepatic encephalopathy
- Refractory to protein restriction and Lactulose or neomycin
- Patient non-compliant
4. Other (Check all that apply):
- Decreased awareness of environment
- Sleep disturbance
- Depression
- Emotional lability
- Somnolence
- Slurred speech
- Obtundation
- Flapping of asterixis (in earlier stages)
- Stupor (late stage)
- Coma (late stage)
2. The following factors have been shown to worsen prognosis and should be documented if present:
- Progressive malnutrition
- Muscle wasting with reduced strength and endurance
- Continued active alcoholism (>80 gm ethanol a day)
- Hepatocellular carcinoma
- HBsAg (Hepatitis B) positivity
- Hepatitis C refractory to interferon treatment
Note: Patients awaiting liver transplant who otherwise fit the above criteria may be certified for hospice, but if a donor organ is procured, the patient should be discharged from hospice.
The patient meets at least one of the following criteria (1 or 2):
a)Dyspnea at rest
b)Vital capacity less than 30%
c)Requirement for supplemental oxygen at rest
d)The patient declines artificial ventilation
Rapid disease progression as evidenced by all of the following in the proceeding twelve (12) months:
a) Progression from independent ambulation to wheelchair or bed-bound status
b) Progression from normal to barely intelligible or unintelligible speech
c) Progression from normal to pureed diet
d) Progression from independence in most or all Activities of Daily Living (ADL’S) to needing major assistance by caretaker in all ADL’S
a) Recurrent aspiration pneumonia (without tube feedings)
b) Pyelonephritis or other upper urinary tract infection
c) Sepsis
d) Recurrent fever after antibiotic therapy
e) Stage 3 or stage 4 decubitus ulcer(s)
In the absence of one or more of the above findings, rapid decline or comorbidities may also support eligibility for hospice care.
1. Critical impaired breathing capacity with all of the following findings:
- Dyspnea at rest
- Vital capacity less than 30%
- The requirement of supplemental oxygen at rest
- The patient declines artificial ventilation
- Progression from independent ambulation to wheelchair or bed bound status
- Progression from normal to barely intelligible or unintelligible speech
- Progression from normal to pureed diet
- Progression from independent in most or all activities of daily living (ADLs) to needing major assistance by caretaker in all ADLs
- Oral intake of nutrients and fluids insufficient to sustain life
- Continuing weight loss
- Dehydration of hypovolemia
- Absence of artificial feeding methods
- Recurrent aspiration pneumonia (with or without tube feedings)
- Upper urinary tract infection (pyelonephritis)
- Sepsis
- Recurrent fever after antibiotic therapy
- Stage 3 or 4 decubitus ulcers
In the absence of one or more of these findings, rapid decline or co-morbidities may also support eligibility for hospice care.
Patients are eligible for hospice care if in the physician’s clinical judgment they have a life expectancy of six months or less. These determinants are to be used as guidelines and do not take the place of a physician’s clinical judgment. Coverage for hospice care may still be appropriate for patients not meeting these determinations due to co-morbidity or rapid decline.
1. Does the patient have severe chronic lung disease?
- Yes
- No
If Yes, both A and B must be present:
A. <Disabling Dyspnea as evidenced by:
- Dyspnea at rest
- House-bound, chair-bound
- Oxygen dependent
- Copious/purulent sputum
- Recurrent infections
- Severe cough
- Poor response to bronchodilators
- Forced expiratory volume in one second (FEV1) after bronchodilator; < 30% of predicted*
- Cyanosis: blue fingertips/lips
- Pulmonary hyperinflation: barrel-chested
- Pursed-lip breathing
- Accessory muscles of respiration
- Retractions: supraclavicular
- Increased expiratory phase: slowed, forced expiration
- Liver
- Diminished breath sounds
- Depressed diaphragm
- Increased visits to Emergency Room or hospitalizations for pulmonary infections/respiratory failure or increased physician home visits
- Decrease in FEV1 on serial testing of > 40 ml/year*
2. Hypoxemia at rest on room air as evidenced by:
- pO2, ≤ 55 mm Hg on supplemental O2
- O2 saturation ≤ 88% on supplemental O2 (through blood gas reports or O2 sat monitors)
- Hypercapnia, as evidenced by pCO2 ≥ 50 mg Hg (within past 3 months)
3. Presence of corpulmonale or right heart failure due to lung disease
4. Unintentional weight loss > 10% of body weight in past 6 months
5. Resting tachycardia (heart rate > per minute)
* These tests are helpful evidence but should not be required if not readily available.
1 and 2 should be present; 3, 4 and 5 lend supporting documentation
1. Patient is not seeking dialysis or renal transplant or is discontinuing dialysis
2. Laboratory criteria for renal failure (one of the following should be present):
- Creatinine clearance of
- Serum creatinine >8.0 mg/dl (>6.0 mg/dl for diabetics)
- Note: Creatinine clearance may be estimated by using the following formula:
Creatinine clearance = (140 – age in years)(body wt. in KG)/72) (serum creatinine in ml/dl) Multiply by 0.85 for women
3. Clinical signs and symptoms associated with renal failure. (Check all which are present):
- Uremia: clinical signs of renal failure:
- Confusion, obtundation
- Intractable nausea and vomiting
- Generalized purities
- Restlessness; “restless legs”
- Oliguria: urine output < 400 cc/24 hours
- Intractable hyperkalemia: persistent serum potassium > 7.0 not responsive to medical management
- Uremic pericarditis
- Hepatorenal syndrome
- Intractable fluid overload, not responsive to treatment
4. Comorbid conditions predict early mortality (Check all that apply):
- Mechanical ventilation
- Malignancy—other organ system
- Chronic lung disease
- Advanced cardiac disease
- Advanced liver disease
- Sepsis
- Immunosupression/AIDS
- Albumen < 3.5 gm/dl
- Cachexia
- IPlatelet count < 25,000
- Age > 75
- Disseminated intravascular coagulation
- GI bleeding
1. <40% decline in Karnofsky Performance Status:
- Mechanical ventilation
- 40 = severely disabled; dependent; requires special care and assistance
- 30 = severely disabled; hospitalized; death not imminent
- 20 = very sick; active supportive treatment needed
- 10 = moribund; fatal processes rapidly progressing
2. Inability to maintain hydration and caloric intake with one of the resulting issues:
- Weight loss >10% in the last 6 months or >7.5% in the last 3 months
- Serum albumin
- Current history of pulmonary aspiration not responsive to speech language pathology intervention
- Sequential calorie counts documenting inadequate caloric/fluid intake
- Dysphagia severe enough to prevent the patient from receiving food and fluids necessary to sustain life—in a patient who declines or does not receive artificial nutrition and hydration.
Documentation to support eligibility for hospice care:
- Non-traumatic hemorrhagic stroke documentation of diagnostic imaging factors which support poor prognosis include:
- large-volume hemorrhage on CT:
- A. infratentorial: 20 ml.
- B. supratentorial: 50 ml.
- ventricular extension of hemorrhage
- surface area of involvement of hemorrhage 30% of cerebrum
- midline shift 1.5 cm.
Thrombotic/embolic stroke documentation of diagnostic imaging factors which support poor prognosis include:
- large anterior infarcts with both cortical and subcortical involvement
- large bihemispheric infarcts
- basilar artery occlusion
- bilateral vertebral artery occlusion
References: Guidelines Taken from: LCD ID Number L13653; LCD Title: Hospice – Determining Terminal Status; Contractor: Cahaba Government Benefit Administrator; Determination # HOA03-002
Karnofsky Scale developed by Karnofsky, Abelmann, Craver & Burchenal, 1948