Medicare Hospice Diagnosis Chart

Medicare Hospice Diagnosis Chart 

Determination of hospice eligibility and prognosis must be made by the patient’s attending physician and the hospice medical director with input from the entire hospice interdisciplinary team. We have included both general and diagnosis-specific criteria designed to assist medical professionals in identifying patients who are eligible for hospice. The following classifications are generally accepted by Medicare:

Supporting documentation for Cancer may include:

  • Clinical findings of malignancy with widespread, aggressive or progressive disease as evidenced by increasing symptoms, worsening lab values and/or evidence of metastatic disease
  • Palliative Performance Scale 70% or less
  • Refuses further life-prolonging therapy OR continues to decline in spite of definitive therapy
  • Hypercalcemia > 12
  • Cachexia or weight loss of 5% in past 3 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.)

Cardiac Disease
Supporting documentation for Cardiac Disease may include:

  • New York Heart Association (NYHA) Class IV
  • Ejection fraction of 20% or less
  • Decline in Karnofsky Performance Status Scale from 70% or less
  • Palliative Performance Scale from 70% or less
  • Unintentional weight loss or gain (Weight gain could be from fluid overload, not representing nutritional status)
  • Shortness of breath or angina at rest or minimal activity
  • Symptoms persist even with optimal doses of diuretics, vasodilators, and/or ACE inhibitors
  • Not a candidate for or declined surgical procedures
  • Increased frequency of ER visits or hospitalizations for symptom control
  • Current inotropic therapy dose unable to be reduced
  • Dependence in 2 or more ADL’s

As of a CMS Ruling issued in May 2013, Debility/Adult Failure to Thrive can no longer be used as a primary diagnosis. A different diagnosis that is “most contributory” to the terminal illness must be selected as the primary. Debility may continue to be used as a secondary condition. Supporting documentation for Debility may include:

  • Progression of disease as documented by symptoms, signs and test results
  • Decline in Karnofsky Performance Status (dependence on assistance with activities daily living) over last 6 months
  • Weight loss of 10% during past 6 months or decreasing triceps skinfold measurements
  • Decreasing serum albumin to < 2.5 gm/dl
  • Dysphagia leading to inadequate nutritional intake (inability or unwillingness to take food or fluids)
  • Decline in ability to perform ADL’s over past 6 months
  • Decline in blood pressure to below 90 systolic or progressive postural hypotension
  • Decline in Functional Assessment Staging (FAST) for dementia (Stage 6 or 7)
  • Progressive stage 3-4 pressure ulcers in spite of optimal care
  • Multiple ER or hospital visits in last 6 months

Supporting Criteria:

  • Aspiration pneumonia, septicemia, or upper UTI in last 12 months
  • Decubitis ulcers, multiple
  • Recurrent fevers after antibiotics

Supporting documentation for Dementia may include:

1. Patient has all the following characteristics

  • Stage 7 or beyond according to the FAST Scale
  • Unable to ambulate without assist
  • Unable to dress without assist
  • Unable to bathe without assist
  • Urinary and fecal incontinence intermittent or constant
  • No meaningful verbal communication: stereotypical phrases only or the ability to speak is limited to six or fewer intelligible words

2. The following may have occurred in the past 12 months

  • Aspiration pneumonia
  • Pyelonephritis or other UTIs
  • Septicemia
  • Pressure ulcers, multiple stage 3-4
  • Recurrent fever after antibiotics
  • 10% weight loss or serum albumin<2.5 gm/dl within the last 6 months

Supporting documentation for HIV/AIDS may include:

  • CD4+ count below 25 cells/mcL measured when a patient is relatively free from acute illness but shoud be followed clinically and observed for disease progression and decline in recent functional status
  • Patients with a persistent HIV RNA (viral load) of > 100,000 copies/ml may have a prognosis less than 6 months
  • Patients who have elected to forego anti-retroviral medication
  • Karnofsky Performance Status Scale from below 50%
  • Palliative Performance Scale below 50%

Please note generally, anti-retroviral therapies such as protease inhibitors are considered life-prolonging.

Liver Disease
Supporting documentation for Liver Disease may include:

  • Karnofsky Performance Status Scale from 70% or less
  • Palliative Performance Scale 70% or less
  • Body Mass Index less than 22 kg/m2
  • Unintentional weight loss or gain
  • Both prothrombin time > 5 sec over control or INR > 1.5 and serum albumin < 2.5 gm/dl
  • End stage liver disease:
    • Ascites unresponsive to treatment
    • Spontaneous bacterial peritonitis
    • Jaundice; hepatic encephalopathy
    • Recurrent variceal bleeding
    • Muscle-wasting with reduced ADLs
    • Hepatorenal syndrome (elevated creatinine, BUN and oliguria (400 cc/24hr) and urine sodium concentration (less than 10 meq/L)

Neurological - CVA, ALS, Parkinsons
Supporting documentation for Neurological (CVA, ALS, Parkinsons) may include:

  • Patient chooses not to elect tracheostomy and invasive ventilation
  • Critically impaired ventilatory capacity
    • Vital Capacity less than 40% of predicted (seated or supine)
    • Significant dyspnea at rest
    • Use of accessory respiratory musculature
    • Requiring oxygen at rest/minimal activity
    • Respiratory rate > 20
    • Reduced speech/vocal volume
  • Severe nutritional deficiency
  • Dysphagia with progressive weight loss of at least 5% of body weight with or without G tube insertion

The two critical factors in determining prognosis for this category are the ability to breathe and the ability to swallow.

Pulmonary Disease
Supporting documentation for Pulmonary Disease may include:

  • Karnofsky Performance Status Scale 70% or less
  • Palliative Performance Scale 70% or less
  • Body Mass Index less than 22 kg/m2
  • Unintentional weight changes
  • Increased frequency of respiratory infections
  • Presence of cor pulmonale or right heart failure
  • Oxygen saturation less than 88% on room air
  • PCO2 greater than or equal to 50mm Hg
  • Disabling dyspnea at rest/minimal activity in spite of continuous oxygen
  • Unresponsive or poorly responsive to bronchodilators, despite optimum medication management
  • Increased frequency of ER visits or hospitalizations for symptom control
  • Increasing dependence on others for ADLs

Renal Disease
Supporting documentation for Renal Disease may include:

  • Karnofsky Performance Status Scale from 70% or less
  • Palliative Performance Scale 70% or less
  • Body Mass Index less than 22 kg/m2
  • Unintentional weight loss or weight gain
  • Creatinine clearance < 10 cc/min or < 15 cc/min for diabetics
  • Serum creatinine > 8.0 mg/dl or 6.0 mg/dl for diabetics
  • Oliguria: Urine output less than 400 cc/24hr
  • Uremia: clinical symptoms of renal failure
    • Confusion
    • Nausea/vomiting
    • Generalized pruritis
    • Restlessness
  • Not seeking dialysis, needed transplant or is discontinuing dialysis

Stroke and Coma
Supporting documentation for a Stroke or Coma may include:

  • Karnofsky Performance Status Scale from 40% or less
  • Palliative Performance Scale 40% or less
  • Body Mass Index less than 22 kg/m2
  • Unintentional weight loss (despite tube feeding) 10% in 6 months or 7.5% in last 3 months
  • Dysphagia without tube feeding
  • Pulmonary aspiration not responsive to speech pathology intervention
  • Serum albumin 2.5 gm/dl or less
  • Age greater than 70
  • Post stroke dementia, with FAST score of 7C or greater
  • Medical complications related to progressive clinical decline over past 12 months
    • Aspiration pneumonia
    • Pyelonephritis
    • Sepsis
    • Skin breakdown, decubitus ulcers, refractory stage 3-4