It’s essential to familiarize yourself with the key local coverage determination (LCD) facts for different terminal illnesses to avoid admitting patients who are not eligible for services only to be required to refund the money back to Medicare; otherwise, only have the patient on for one benefit period then discharged for failure to decline. These determinations provide guidelines on the coverage of hospice services for specific conditions. If you are the admitting nurse, please do not just admit because you were told to admit by someone, regardless of the position or standing of the person or party that told you to admit. Use your critical thinking and clinical judgment skills to evaluate the patient for admission. Most doctors will write “evaluate and treat” or something to that effect; never lose sight of the “evaluate” portion of the doctor’s order.
Based on the provided PDF files, as noted in the resources section below, let’s explore some essential information for each terminal illness.
Amyotrophic Lateral Sclerosis (ALS)
Key LCD Facts:
ALS is a progressive neurodegenerative disease that affects nerve cells in the brain and spinal cord.
Patients diagnosed with ALS are eligible for hospice care based on specific criteria, including declining functional status, swallowing difficulties, respiratory insufficiency, and more.
LCD provides guidelines on the necessary documentation to support ALS patients’ terminal status.
Symptom management focuses on addressing respiratory issues, pain, dysphagia, and emotional support for the patient and their family.
Critical Compliance Criteria:
Patients will be considered to be in the terminal stage of ALS (life expectancy of six months or less) if they meet the following criteria. (Should fulfill 1, 2, or 3):
The patient should demonstrate critically impaired breathing capacity
The patient should demonstrate both rapid progression of ALS and critical nutritional impairment.
The patient should demonstrate both rapid progression of ALS and life-threatening complications.
Dementia and Alzheimer’s disease are progressive neurological disorders characterized by cognitive decline and memory loss.
Hospice eligibility for patients with dementia and Alzheimer’s disease depends on factors such as functional decline, cognitive impairment, complications, and comorbidities.
The LCD guides documenting cognitive and functional decline to support terminal status certification.
Symptom management focuses on addressing pain, behavioral disturbances, communication difficulties, and emotional support for both the patient and their family.
Critical Compliance Criteria:
Patients will be considered to be in the terminal stage of dementia (life expectancy of six months or less) if they meet the following criteria. Patients with dementia should show all the following characteristics:
Stage seven or beyond according to the Functional Assessment Staging Scale;
Unable to ambulate without assistance;
Unable to dress without assistance;
Unable to bathe without assistance;
Urinary and fecal incontinence, intermittent or constant;
No consistently meaningful verbal communication: stereotypical phrases only or the ability to speak is limited to six or fewer intelligible words.
Patients should have had one of the following within the past 12 months:
Heart disease encompasses various conditions affecting the heart, such as congestive heart failure, coronary artery disease, and cardiomyopathy.
Hospice eligibility for heart disease patients depends on criteria such as advanced symptoms, recurrent hospitalizations, and a limited prognosis.
The LCD outlines the necessary documentation to support the terminal status determination for heart disease patients.
Symptom management addresses symptoms like dyspnea, edema, pain, and fatigue and emotionally supports patients and their families.
Critical Compliance Criteria:
Patients will be considered to be in the terminal stage of heart disease (life expectancy of six months or less) if they meet the following criteria. (1 and 2 should be present. Factors from 3 will add supporting documentation.):
At the time of initial certification or recertification for hospice, the patient is or has already been optimally treated for heart disease, is not a candidate for a surgical procedure, or has declined a procedure. (Optimally treated means that patients who are not on vasodilators have a medical reason for refusing these drugs, e.g., hypotension or renal disease.)
The patient is classified as New York Heart Association (NYHA) Class IV and may have significant symptoms of heart failure or angina at rest. (Class IV patients with heart disease cannot carry on any physical activity without discomfort. Symptoms of heart failure or anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort is increased.) Significant congestive heart failure may be documented by an ejection fraction of ≤20% but is not required if not already available.
Documentation of the following factors will support but is not required to establish eligibility for hospice care: a. Treatment-resistant symptomatic supraventricular or ventricular arrhythmias. b. History of cardiac arrest or resuscitation. c. History of unexplained syncope. d. Brain embolism of cardiac origin. e. Concomitant HIV disease.
Liver disease includes conditions like cirrhosis, hepatitis, and liver failure, which result in progressive liver damage and impaired liver function.
Hospice eligibility for liver disease patients depends on criteria such as complications, signs of decompensation, hepatorenal syndrome, and a limited prognosis.
The LCD outlines the documentation to support the terminal status determination for patients with liver disease.
Symptom management focuses on addressing symptoms like ascites, hepatic encephalopathy, pruritus, and fatigue and providing emotional support to patients and their families.
Critical Compliance Criteria:
Patients will be considered to be in the terminal stage of liver disease (life expectancy of six months or less) if they meet the following criteria. (1 and 2 should be present; factors from 3 will lend supporting documentation.):
The patient should show both a and b: a. Prothrombin time prolonged over 5 seconds over control, or International Normalized Ratio (INR) >1.5; b. Serum albumin <2.5 gm/dl
End-stage liver disease is present, and the patient shows at least one of the following: a. Ascites, refractory to treatment, or patient non-compliant; b. Spontaneous bacterial peritonitis; c. Hepatorenal syndrome (elevated creatinine and BUN with oliguria); d. Hepatic encephalopathy, refractory to treatment, or patient non-compliant; e. Recurrent variceal bleeding despite intensive therapy.
Documentation of the following factors will support eligibility for hospice care: a. Progressive malnutrition; b. Muscle wasting with reduced strength and endurance; c. Continued active alcoholism (>80 gm ethanol/day); d. Hepatocellular carcinoma; e. HBsAg (Hepatitis B) positivity; f. Hepatitis C refractory to interferon treatment.
Remember, these are just a few examples of terminal illnesses commonly seen in hospice care. Each terminal illness has specific LCD criteria, documentation requirements, and symptom management considerations.
The most common questionable (and I’m using this word lightly) areas that happen during admissions include the following:
Admitting Alzheimer’s patients without a FAST scale rating, during the admission when the patient is sleeping or napping, or otherwise during circumstances that do not allow a thorough and detailed exam to obtain the appropriate FAST scale at the time of the admission.
Admitting Alzheimer’s Patients whose FAST scale is less than 7A or putting down 7A just because the patient is walking (therefore not FAST 7C), and the admitting nurse was told to admit or otherwise did not question the admission.
Admitting Dementia patients where the FAST scale may not be appropriate and yet the patient is functional enough to manage all their independent activities of daily living (IADL) and the like.
Admitting congestive heart failure (CHF) patients or patients with chronic obstructive pulmonary disease (COPD) who are not only on room air but also not short of breath at rest and minimally (if at all) short of breath with activity (dyspnea on exertion/DOE).
When patients are admitted to hospice when they do not qualify, not only is that a black eye for the field of hospice… not only does it make life more difficult for the case manager and the entire care team, but it is an egregious disservice to the patient and the family especially when the patient is discharged for failure to decline.
