Hospice Eligibility Graphic

It's important 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 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 and clinical judgement skills as part of evaluating 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.

Let's explore some essential information for each terminal illness based on the provided PDF files as noted in the resources section below.

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, , 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):

  1. Patient should demonstrate critically impaired breathing capacity
  2. Patient should demonstrate both rapid progression of ALS and critical nutritional impairment.
  3. Patient should demonstrate both rapid progression of ALS and life-threatening complications

Resources: Amyotrophic Lateral Sclerosis (ALS) — Hospice Terminal Prognosis

Dementia and Alzheimer’s Disease

Key LCD Facts:

  • Dementia and Alzheimer's disease are progressive neurological disorders characterized by cognitive decline and memory loss.
  • for patients with dementia and Alzheimer's disease depends on factors such as , cognitive impairment, complications, and comorbidities.
  • The LCD provides guidance on documenting cognitive and 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:

  1. Stage seven or beyond according to the Functional Assessment Staging Scale;
  2. Unable to ambulate without assistance;
  3. Unable to dress without assistance;
  4. Unable to bathe without assistance;
  5. Urinary and fecal incontinence, intermittent or constant;
  6. 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:

  1. Aspiration pneumonia;
  2. Pyelonephritis or other upper urinary tract infection;
  3. Septicemia;
  4. Decubitus ulcers, multiple, stage 3-4;
  5. Fever, recurrent after ;

Resources: Dementia and Alzheimer's Disease — Hospice Terminal Prognosis

Heart Disease

Key LCD Facts:

  • Heart disease encompasses various conditions affecting the heart, such as congestive heart failure, coronary artery disease, and cardiomyopathy.
  • 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 focuses on addressing symptoms like dyspnea, edema, pain, fatigue, and providing emotional support to 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.):

  1. At the time of initial certification or recertification for hospice, the patient is or has been
    already optimally treated for heart disease or 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.)
  2. 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
    have an inability to carry on any physical activity without . Symptoms of heart failure
    or of the anginal syndrome may be present even at rest. If any physical activity is undertaken,
    is increased.) Significant congestive heart failure may be documented by an
    ejection fraction of ≤20% but is not required if not already available.
  3. 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.

Resources: Heart Disease — Hospice Terminal Prognosis

Liver Disease

Key LCD Facts:

  • 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 necessary documentation to support the terminal status determination for patients with liver disease.
  • Symptom management focuses on addressing symptoms like ascites, hepatic encephalopathy, pruritus, 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.):

  1. 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.
  2. 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.

Resources: Liver Disease — Hospice Terminal Prognosis

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 rating or 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 (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 clearly 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.

Resources

What's the process of getting your loved one on hospice service?

Hospice Quick Flips — a handy tool for admissions and recertifications

Hospice Determining Terminal Status

Amyotrophic Lateral Sclerosis

Dementia due to Alzheimer's Disease

Heart Disease

HIV

Liver Disease

Non-disease specific

Pulmonary Disease

Renal Disease

Stroke and Coma

Hospice Quick Resource Tools

My Loved One with Dementia

Understanding Dementia (Alzheimer's & Vascular & Frontotemporal & Lewy Body Dementia) (Video)

How Do I Know Which Dementia I'm Looking At? (Video)

Dementia Training material (Free)

Promoting Meaningful Relationships with Dementia Patients through Validation Therapy

Unlocking the Power of Validation Therapy in Compassionate End-of-Life Care

Validation Therapy: A Valuable Tool for Families and Healthcare Teams

Best Practices for Approaching Combative Dementia Patients

The Validation Breakthrough: Simple Techniques for Communicating with People with Alzheimer's Disease and Other Dementias

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How Do I Know You? Dementia at the End of Life

The Dementia Caregiver: A Guide to Caring for Someone with Alzheimer's Disease and Other Neurocognitive Disorders (Guides to Caregiving)

Sundown Dementia, Vascular Dementia and Lewy Body Dementia Explained

The Caregiver's Guide to Dementia: Practical Advice for Caring for Yourself and Your Loved One (Caregiver's Guides)

Ahead of Dementia: A Real-World, Upfront, Straightforward, Step-by-Step Guide for Family Caregivers

The Dementia Caregiver's Survival Guide: An 11-Step Plan to Understand the Disease and How To Cope with Financial Challenges, Patient Aggression, and Depression Without Guilt, Overwhelm, or Burnout

Dementia Care Companion: The Complete Handbook of Practical Care from Early to Late Stage

Providing Comfort During the Last Days of Life with Barbara Karnes RN (YouTube Video)

Preparing the patient, family, and caregivers for a “Good Death”

Velocity of Changes in Condition as an Indicator of Approaching Death (often helpful to answer how soon? or when?)

The Dying Process and the End of Life

The Last Hours of Life

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Gone from My Sight: The Dying Experience

The Eleventh Hour: A Caring Guideline for the Hours to Minutes Before Death

By Your Side , A Guide for Caring for the Dying at Home

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