Home Health & Hospice Week

Train your clinicians on what reviewers will be looking for.

How do you prove that your patient with Alzheimer's Disease qualifies for the hospice benefit with a six-month prognosis? Look to one MAC's coverage guidelines for clues.

Medicare is cracking down on long-stay hospice patients (see related story, p. 47). In the fourth quarter of 2011, one of hospices' top denial reasons was for terminal prognosis, HHH MAC NHIC said in a Hospice POE Advisory Group Meet-ing earlier this year. Slow-declining diagnoses such as Alzheimer's were most common in the denials, NHIC said according to the meeting minutes.

Smart hospices will make sure their documentation for such patients meets guidelines for payment. HH&H Medicare Administrative Con-tractor CGS addresses specific documentation requirements for cancer and eight non-cancer diagnoses in its Local Coverage Determination (LCD), "Determining Terminal Status" (L32015).

Cover General Requirements First

Before getting into disease-specific particulars, clinicians should document some basic elements common to all terminal conditions. The record should show physiologic impairment of functional status as demonstrated by the Karnofsky Performance Status (KPS) or Palliative Performance Score (PPS) of less than 70 percent, CGS says in the LCD.

Exception: Two of the disease specific guidelines (HIV Disease, and Stroke and Coma) establish a lower qualifying KPS or PPS.

Documentation also should establish depen-dence on assistance for two or more activities of daily living (ADLs): feeding, ambulation, continence, transfer, bathing, and dressing.

Hit These 6 Documentation Points

In conjunction with the non-disease specific guidelines CGS lays out in the LCD, clinicians should cover these bases in their documentation to prove patients with Alzheimer's Disease and other related disorders are in their terminal stage:

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 also should have had one of the following within the past 12 months, CGS says in the LCD:

1. Aspiration pneumonia;

2. Pyelonephritis or other upper urinary tract infection;

3. Septicemia;

4. Decubitus ulcers, multiple, stage 3-4; or

5. Fever, recurrent after antibiotics;

6. Inability to maintain sufficient fluid and calorie intake with 10 percent weight loss during the previous six months or serum albumin <2.5 gm/dl.

Note: For a free copy of the LCD, which also contains disease-specific guidelines for cancer, ALS, heart disease, HIV, liver disease, pulmonary disease, renal disease, and stroke and coma, e-mail editor Rebecca Johnson at rebeccaj@eliresearch.com with "Terminal Status LCD" in the subject line.