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Welcome to Physician’s Corner, this page is designed to help clinicians work through the nuts and bolts of
hospice appropriate criteria. We also offer a link to a quarterly newsletter,
Quality of Life Matters, designed for end-of-life care news
and clinical findings for physicians as an educational service by Hospice Complete.
Click here to go to our Events page to download the latest quarterly edition of
Quality of Life Matters and scroll through our archive
section to review past editions. Hospice Complete would also like to provide its physicians with a basic
instruction sheet on how to handle physician billing issues for hospice patients.
Click here to download physician billing for
hospice patients.
Hospice Criteria
Medicare has criteria for non-cancer diagnoses to help determine a prognosis. Medicare realizes that physicians
can only estimate the life expectancy of a patient diagnosed with a terminal illness. This is why Medicare
changed their prognosis criteria to read that a patient has a statistical probability of around 50% if a
patient meets the hospice criteria, the patient will have a life expectancy of 6 months or less if the illness
runs its normal course. This information is taken directly from Palmetto (PGBA) Medicare Advisory
Criteria for Non-cancer Diagnoses
Amyotrophic Lateral Sclerosis
The patient must have 1 or 2 AND 3 or 4
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(1) |
Progression of decline in the last 12 months—Must have all of the following: |
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-from independent ambulation to wheelchair or bedbound |
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-from normal to barely intelligible speech |
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-from normal to pureed diet |
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-from independence to assisted ADL’s |
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(2) |
Critically impaired ventilatory capacity—Must have all of the following: |
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-vital capacity less that 30% of predicted (if available) |
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-supplemental oxygen required at rest |
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-significant dyspnea at rest |
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-mechanical ventilation refused |
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(3) |
Critical nutritional impairment—Must have all of the following: |
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-chronic dehydration |
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-oral intake insufficient and artificial feeding refused |
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-continued weight loss |
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(4) |
Life threatening complications—Must have all of the following: |
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-recurrent aspiration pneumonia |
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-multiple stage 3 or 4 decubitus ulcers |
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-sepsis |
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-recurrent fever after antibiotics |
CAD or CHF:
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Shortness of breath at rest or frequent chest pain (Class IV Symptoms) or an EF of <20% |
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Taking a vasodilator and diuretic medication (Optimal Treatment) |
COPD:
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Short of Breath (Must be on home O2 Therapy) |
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Chronic Bronchitis |
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O2 SAT <=88% or PO2 <=55 on supplemental oxygen or PCO2 >=50 |
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Tachycardia at rest |
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Frequent ER visits or hospitalizations over the last year |
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Cardiac rhythm abnormalities |
Stroke or Coma:
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Assistance with ambulation |
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Assistance with dressing |
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Assistance with bathing |
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Incontinence of B/B (constant or intermittent) |
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Difficulty communicating needs |
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Karnofsky score <=40 |
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Weight loss - 10% over last six months |
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Serum Albumin <2.5 |
DEMENTIA / Alzheimers
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ALL OF THE FOLLOWING MUST BE PRESENT: |
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1. Ability to speak limited to 1 - 5 words per day |
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2. All intelligible vocabulary lost |
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3. Non-ambulatory |
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4. Unable to sit up independently |
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5. Unable to smile |
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6. Unable to hold head up |
End Stage Liver Disease
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INR >1.5 or PT prolonged <5 seconds over control |
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Serum Albumin <2.5 |
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One of the following complications: |
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-ascites |
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-bacterial peritonitis |
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-hepatorenal syndrome |
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-hepatic encephalopathy |
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-recurrent variceal bleeding |
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-patient non-compliant |
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-concomitant elevated creatnine and BUN or oliguria < 400cc/day |
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-malnutrition/muscle wasting/reduced strength or endurance |
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-continued active alcoholism |
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-refractory to sodium restrictions and diuretics |
End Stage Renal Disease
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Must have one of the following diagnoses: |
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1. End Stage Renal Disease |
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2. Renal Failure, Unspecified |
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3. Acute Renal Failure with Lesion of Tubular Necrosis |
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4. Hypertensive Chronic Kidney Disease, Benign, with Chronis
Kidney Disease Stage V or End Stage Renal Disease |
HIV
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CD4 count <25 or Persistent viral load of >100,000 |
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One of the following life threatening complications: |
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-CNS Lymphoma |
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-Cryptosporidiosis |
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-MAC Bacteremia, untreated |
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-Systemic lymphoma, unresponsive to Rx |
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-Progressive multifocal leukoencephalopathy |
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-Wasting Syndrome (>33% lean mass lost) |
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-Visceral Kaposi's Sarcoma, unresponsive to Rx |
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-Toxoplasmosis, unresponsive to Rx |
Adult Failure to Thrive
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No known or reversible cause identified for the patient’s nutritional impairment |
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Body Mass Index <22 {703 x (weight in pounds) ÷ (height in inches)²} |
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Nutritional support declined or no improvement with nutritional support |
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Karnofsky score = 40% |
Cancer
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Primary site and Diagnosis date needed. |
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Has the patient received past chemotherapy or radiation therapy? |
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Is the patient currently receiving chemotherapy or radiation therapy? |
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Is the statistical prognosis for a patient at this stage less than 50% survival at six months? |
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List the plan for future therapy. |
With these criteria we must remember that these are only guidelines given by Medicare and many factors
come into play when a patient has been diagnosed with a terminal illness. Please remember our staff
can make an evaluation visit on any patient you feel is appropriate as long as your office gives Hospice
Complete permission. Our nurse will make an evaluation visit and contact your office to inform you regarding
the findings from our nursing assessment. If the patient meets the criteria, Hospice Complete will be able
to admit the patient to our hospice program by obtaining a verbal order from you, the physician.
Please contact our office for more information.
Hospice Complete
Phone (205) 988-8669
referral@hospicecomplete.net
info@hospicecomplete.net
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Physician's Corner
CMS Hospice Benefit
