Hospice Appropriate Diagnoses


Article Author:
Dac Teoli


Article Editor:
Abhishek Bhardwaj


Editors In Chief:
Alexandra Caley
Sameh Boktor


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
2/9/2019 11:25:38 PM

Definition/Introduction

Hospice is a medical service based on a holistic approach to providing quality end-of-life care to patients. Typically, there is an interdisciplinary team-focus led by a physician medical director. Often, these physicians who manage and monitor care during the length of service have additional training beyond residency by completing a dedicated fellowship, thereby earning board certification in the medical subspecialty of hospice and palliative medicine.

In essence, most patients have multiple conditions which could potentially be hospice-appropriate diagnoses. The basic foundation of hospice is offering palliative and complex symptomatic management to those with a life expectancy of six months or less. There are several layers of thought which need to be addressed before establishing current status and maintaining status on hospice services. Some diagnoses are chronic and stable without a meaningful impact on terminal prognosis. Some treatments for chronic conditions may cause more harm than good during the terminal stages of life. Alternatively, therapies might fall into the non-palliative category or be futile given the stage of the disease. For each patient, there must be a complete evaluation of the totality of their conditions, including hospice-appropriate diagnoses, and treatment plans.

Research has shown that hospice does improve the quality of life in patients. However, hospice patients live only 2.5 months, on average, once being provided a six-month prognosis by their primary physician and enrolled. This statistic lends risk to the common misconception that hospice services hasten death; however, in reality, it points to the issue that patients are very often brought onto hospice services later than which they were eligible. In other words, hospice services are for patients with a prognosis of 6 months or less until their death, yet patients are not utilizing hospice services until only 2.5 months until death. Why this is the case will indeed require further research; however, what is known is that, by patients being eligible for months before the referral eventually is made, patients are missing out on the numerous benefits that a comprehensive hospice service can provide to its patient population.

Enrollment into hospice service is not as simple as a patient’s primary physician making a prognosis of fewer than six months to live. On the contrary, there are many details which need to be considered and meticulously assessed and documented for a patient to successfully transition into hospice. As with each new set of guidelines, revised standards, or updated ICD codes, there are further changes to the interpretation and guidance of hospice diagnoses and regulations. Similarly, there is a consistent rolling out of new expectations by CMS regarding billing and coding.

While the assessment of appropriate hospice diagnoses can be confusing for healthcare providers that are not required to stay abreast of the literature constantly, hospice physicians and organizations can offer valuable services to help answer questions and provide guidance. Hospice organizations can assist determine eligibility for patients suffering from terminal illness. These same organizations can often provide thoughtful guided conversations with patients and their families about the benefits their services offer. As the process of gaining approval can be complicated, it is generally smiled upon to refer eligible patients to hospice services soon after a terminal diagnosis is rendered to help integrate excellent longitudinal care. Overall, the hospice organizational agency is responsible for all patients in their care, to ensure their satisfaction of eligibility criteria for hospice and that their services are medically necessary.

As noted earlier, CMS has consistently updated its approach to hospice-appropriate diagnoses. Most recently CMS has migrated away from only a primary hospice diagnosis and instead toward inclusion of all relevant and non-related conditions that impact prognosis or the underlying terminal condition. Uniform Hospital Discharge Data Set defines the primary or principal diagnosis as the “condition after study chiefly responsible for causing admission of the patient to the hospital.” Another way of understanding it is that the principal diagnosis is the one seen as most contributing to the 6-month prognosis for the patient. If there happen to be two hospice-appropriate diagnoses which are felt to contribute to the patient’s poor prognosis equally, requirements are that both be documented as the principal diagnosis, with sequencing between the two inconsequential.

Diagnoses are understandably dynamic. Diagnoses might change and need to be documented, with additions and deletions, as a patient progresses through the terminal stages of their conditions. In fact, static diagnoses over time might falsely convey stability of a patient’s condition and theoretical re-evaluation of the patient as being an appropriate hospice candidate.

In respect to determining a patient’s terminal prognosis, with a life expectancy of six months or less, often individuals have multiple hospice appropriate diagnoses, and all diagnoses must be confirmed by a physician or provider which bears legal accountability for establishing diagnoses for the patient.[1][2][3][4]

Issues of Concern

Most of the issues of concern regarding hospice-appropriate diagnoses revolve around gaining and maintaining approval and billing/coding concerns. Specifically, frequently noted areas of concern involve successful utilization of symptom codes, use of combination codes, and successfully coding diagnoses which are not obviously listed in the manuals. Other areas of more recent concern involve specific diagnoses such as ambiguities involving dementia, establishing a fracture as the primary diagnosis, appropriately sequencing primary versus secondary neoplasms, and accurately documenting cerebrovascular diagnoses which are acute versus late effect codes.[5][6]

Clinical Significance

Each patient must be seen as a unique person. Many diagnoses and conditions can impact the care of patients during the last stages of life. Documentation should aim to be complete, clear, and factual regarding the patient’s circumstances and the impact their diagnoses have on their prognosis. There should be a frequent re-evaluation of the patient’s status as appropriate for continued hospice care through the lens of physical, mental, social and spiritual needs. CMS requests coding of all current diagnoses in the documentation. Therefore, diagnoses made in the past that have no bearing on the patient’s current status or ongoing prognosis (history codes) should be removed per coding guidelines. Hospice claims can support up to twenty-five diagnoses and if there are some diagnoses without designated codes or for whatever reason cannot be placed in the diagnoses section, those conditions can receive coverage in the narrative part of the plan of care in the documentation. Overall the process of enrolling patients into hospice and determining hospice-appropriate diagnoses requires critical thinking by the physician, with maintaining a current list of conditions and removing inappropriate history codes when applicable.

For reference, below an abridged version of the currently outlined assessment criteria for the progression of diseases and non-disease baseline guidelines as obtained from the Centers of Medicare and Medicaid Services:

Part 1: Decline in a patient's clinical status guidelines

A. Progression of disease via worsening status, symptoms, signs, laboratory results:

Clinical Status:

  • Refractory or recurring infections
  • Progressive inanition which is documented by several measures such as 10% body weight loss, decreased albumin, dysphagia leading to aspiration, among others

Symptoms:

  • Include a number of symptoms including nausea and vomiting, dyspnea, persisting cough, diarrhea, and progressive pain

Signs:

  • Include a number of clinical signs including hypotension, edema, ascites, progressive weakness, new altered mental status, among others

Laboratory Results:

  • Include a number of laboratory findings including worsening pCO2/pO2/SaO2 values, worsening liver function tests, worsening tumor markers, and volatile sodium and potassium, among others

B. Progressive disease leading to worsened Karnofsky Performance Status or Palliative Performance Score

C. Worsened Functional Assessment Staging of diagnosed dementia.

D. Requiring assistance with additional ADL's

E. Worsening refractory stage 3 to stage 4 pressure ulcers despite wound care

F. Increasing healthcare utilization in the form of emergency visits, hospital admissions, and physician appointments related to the primary hospice diagnosis before seeking hospice benefit

 Part 2. Non-disease specific baseline guidelines (both points A and B must be satisfied).

A. Physiologic impairment of functional status as interpreted via the Karnofsky Performance Status or Palliative Performance Score of less than 70 percent

B. Individual needs assistance for greater than or equal to 2 ADL's: Ambulation; Transfer; Dressing; Feeding; Continence; Bathing.

C. Co-morbidities: when the condition is not the designated primary hospice diagnosis, the presence of significant disease thought to contribute to a prognosis of 6 months or less survival should be considered, such as[7][8][9][10]:

  • COPD
  • CHF
  • Ischemic heart disease
  • Diabetes mellitus
  • Neurologic disease (CVA, ALS, MS, Parkinson's)
  • Renal failure
  • Liver Disease
  • Neoplasia
  • Acquired immune deficiency syndrome/HIV
  • Dementia
  • Refractory severe autoimmune disease (e.g., lupus or rheumatoid arthritis)

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Hospice Appropriate Diagnoses - Questions

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Which of the following individuals is a candidate for hospice care?



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Select the choice which is FALSE concerning hospice care:



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Select the choice which is NOT on the list of major diagnoses seen in hospice:



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Which of the following patients may not be eligible for hospice care under the Medicare hospice benefit?



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In determining six months life expectancy for both HIV or end-stage liver disease patient the single most aggressive factor is which of the following?



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A 74-year-old male presents to the palliative clinic after being referred by his oncologist. The patient has a history of hypertension, diabetes mellitus, hypothyroidism, and metastatic colon cancer with debilitating pain severely impacting his quality of life. The patient requests to be provided with information about hospice for end-of-life care. After discussing the matter further, the patient chooses to proceed. When the palliative team completes eligibility paperwork for this patient to CMS for this service, which of the following is most likely to cause a delay in approval status?



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A 56-year-old female presents to the palliative clinic after being referred by her primary care physician. The patient has a prognosis of 8 months with a medical history of factor V Leiden, hypertension, lupus, and breast cancer with metastasis to bilateral lungs. Her metastatic disease has begun to cause dyspnea, impacting her quality of life, and she continues to receive chemotherapy with a curative goal. She has a session of palliative radiation therapy scheduled for three weeks from today. The patient requests to be provided with information about hospice care. After discussion, the patient chooses to proceed with hospice, and the appropriate paperwork is filed with CMS. One week later, the palliative team receives a rejection notification regarding this patient's request for hospice services. It is indicated that eligibility requirements have not been met. Which of the following is most likely to ameliorate the deficiency and thereby gain CMS approval?



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A 44-year-old woman presents to the multidisciplinary neighborhood clinic to learn more about hospice care. The patient has a history of hepatitis-induced cirrhosis and pulmonary hypertension with debilitating dyspnea despite supplemental oxygen. The patient's grandmother received hospice through the same clinic ten years ago, however, despite her request today, the clinic regretfully informs the woman that they no longer coordinate, organize, and deliver hospice care. The clinic manager states specific reasons identical to the most commonly cited clinician-side point of concern regarding CMS hospice services. Which of the following, if adopted, would best address the nature of these ubiquitous concerns?



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A 62-year-old female presents for assessment for hospice services. The patient has a history of lung cancer with debilitating abdominal and bone pain due to metastasis severely impacting her quality of life. After discussing the matter further with the palliative physician, the patient chooses to proceed. The appropriate paperwork is filed, and four days later, a rejection letter is received by the clinic. The submitted forms describe the patient as a "62-year-old female with lung cancer and bone cancer, with significant pain, and a prognosis of five months." What correction to the paperwork is most likely to resolve the near-immediate cause of rejection?



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Hospice Appropriate Diagnoses - References

References

Buss MK,Rock LK,McCarthy EP, Understanding Palliative Care and Hospice: A Review for Primary Care Providers. Mayo Clinic proceedings. 2017 Feb;     [PubMed]
Wallace CL, Examining hospice enrollment through a novel lens: Decision time. Palliative     [PubMed]
Wang X,Knight LS,Evans A,Wang J,Smith TJ, Variations Among Physicians in Hospice Referrals of Patients With Advanced Cancer. Journal of oncology practice. 2017 May;     [PubMed]
Cheraghlou S,Gahbauer EA,Leo-Summers L,Stabenau HF,Chaudhry SI,Gill TM, Restricting Symptoms Before and After Admission to Hospice. The American journal of medicine. 2016 Jul;     [PubMed]
Dolin R,Hanson LC,Rosenblum SF,Stearns SC,Holmes GM,Silberman P, Factors Driving Live Discharge From Hospice: Provider Perspectives. Journal of pain and symptom management. 2017 Jun;     [PubMed]
Cherlin EJ,Brewster AL,Curry LA,Canavan ME,Hurzeler R,Bradley EH, Interventions for Reducing Hospital Readmission Rates: The Role of Hospice and Palliative Care. The American journal of hospice     [PubMed]
Jones BW, Evidence-based practice in hospice: is qualitative more appropriate than quantitative? Home healthcare nurse. 2013 Apr;     [PubMed]
Kaufman BG,Klemish D,Kassner CT,Reiter JP,Li F,Harker M,O'Brien EC,Taylor DH Jr,Bhavsar NA, Predicting Length of Hospice Stay: An Application of Quantile Regression. Journal of palliative medicine. 2018 Aug;     [PubMed]
Goy ER,Bohlig A,Carter J,Ganzini L, Identifying predictors of hospice eligibility in patients with Parkinson disease. The American journal of hospice     [PubMed]
Wladkowski SP,Wallace CL, Current Practices of Live Discharge from Hospice: Social Work Perspectives. Health     [PubMed]

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