Approved Hospice Diagnosis List: Understanding Eligibility Criteria for Hospice Care

Introduction

When facing a life-limiting illness, hospice care offers compassionate and comprehensive support, focusing on enhancing quality of life for patients and their families. Understanding the criteria for hospice eligibility is crucial for both healthcare providers and individuals seeking this specialized care. While there isn’t a simple “Approved Hospice Diagnosis List” that automatically qualifies someone, there are established guidelines that outline medical conditions and specific clinical findings that indicate a prognosis of six months or less, making a patient eligible for hospice benefits. This article provides a detailed overview of these guidelines, drawing from established medical criteria to clarify the process of determining hospice eligibility. It aims to be a helpful resource for navigating the complexities of hospice admission based on diagnosis and overall health status.

General Hospice Eligibility Guidelines

To ensure that patients receive hospice care when it is most appropriate, there are general guidelines that apply across all diagnoses. These guidelines emphasize the need for thorough documentation and clinical judgment in determining a patient’s eligibility. The core principle is that the patient’s medical condition, as documented, must support a prognosis of a life expectancy of six months or less if the illness runs its normal course.

Documentation Requirements

Comprehensive documentation is paramount in the hospice eligibility determination process. This documentation should effectively “paint a picture” for reviewers, clearly illustrating why hospice care is appropriate for the patient and justifying the level of care being provided (routine home care, continuous home care, inpatient respite care, or general inpatient care).

The medical records should emphasize objective observations and data rather than mere conclusions. For instance, instead of stating “patient is declining,” the documentation should include specific observations such as “patient requires assistance with dressing and bathing,” “experiences shortness of breath at rest,” or “has experienced a 10% weight loss in the past six months.” These specific details provide concrete evidence of the patient’s declining health status.

Documentation practices should align with standard clinical documentation norms. Unless there are elements in the record that require further explanation, such as a non-terminal diagnosis alongside indicators suggesting a prognosis of six months or less, or factors suggesting a longer survival period, no additional or excessive record entries are typically needed to demonstrate hospice benefit eligibility.

The level of detail in documentation will vary depending on the patient’s condition. For a patient with metastatic small cell carcinoma, demonstrating hospice eligibility may require less extensive documentation compared to a patient with chronic lung disease. This is because certain conditions, like metastatic cancer, inherently carry a poorer prognosis. However, patients with chronic conditions, those who have been in hospice care for an extended period, or those whose condition appears stable can still be hospice eligible, but the documentation must provide sufficient justification for a prognosis of less than six months.

If the medical documentation includes any findings that contradict or question a prognosis of less than six months, these discrepancies must be addressed and clarified within the record. For example, if a patient shows improvement in certain functions or if there are opinions from team members suggesting a longer prognosis, these points need to be specifically addressed and explained in the context of the overall terminal trajectory. Similarly, the absence of certain documentation elements, such as a tissue diagnosis for cancer, does not automatically disqualify a patient from hospice, but it necessitates stronger supportive documentation in other areas.

Pertinent information from periods outside the current billing review period can be included in the submitted documentation to provide a complete clinical picture. This can include significant events such as changes in activities of daily living, recent hospitalizations, and, if applicable, the known date of death, especially when billing for a period preceding the month of death.

Finally, documentation must consistently support the level of hospice care being provided throughout the review period. Reviewers should be able to easily identify the dates and times of any changes in the level of care and the clinical reasons for these changes. Adherence to the requirements outlined in CMS IOM Publication 100-02, Chapter 9, Section 20 is also mandatory for hospice documentation.

Disease-Specific Hospice Eligibility Guidelines

In addition to the general guidelines, there are disease-specific guidelines that provide more detailed criteria for determining hospice eligibility based on particular diagnoses. These guidelines are designed to be used in conjunction with the general principles outlined above.

Cancer Diagnoses

For patients with cancer, hospice eligibility is often considered when the disease has reached an advanced stage. Specific criteria include:

A. Disease with distant metastases at presentation OR

B. Progression from an earlier stage of disease to metastatic disease with either:

1. A continued decline in spite of therapy
2. Patient declines further disease-directed therapy

These criteria highlight that hospice care is appropriate when cancer has spread (metastasized) and is either present at distant sites upon initial diagnosis or has progressed to metastasis from a localized stage. Furthermore, the patient should be demonstrating ongoing decline despite active cancer treatments, or they have chosen to discontinue further aggressive, disease-directed treatments.

It is important to note that certain cancers known for their aggressive nature and poor prognosis, such as small cell lung cancer, brain cancer, and pancreatic cancer, may qualify for hospice even without meeting all the criteria listed above. Clinical judgment plays a crucial role in these cases, considering the typically rapid and severe disease trajectory associated with these specific cancer types.

Non-Cancer Diagnoses

For non-cancer diagnoses, the criteria for hospice eligibility are tailored to the specific disease and its typical progression.

Amyotrophic Lateral Sclerosis (ALS)

General Considerations for ALS:

1. ALS typically progresses in a relatively linear and predictable manner, making the rate of decline fairly consistent for individual patients compared to many other non-cancer illnesses.
2. However, the rate of deterioration varies significantly between individuals for any single parameter. Therefore, assessing ALS progression and prognosis requires considering multiple clinical factors rather than relying on a single measure.
3. While ALS often begins in a localized area, the initial site of onset does not reliably predict survival time. As the disease advances, muscle weakness and denervation become widespread, affecting all areas of the body, and initial patterns of weakness become less relevant in determining prognosis.
4. The rate of disease progression differs markedly among patients. Some experience rapid decline and shorter survival, while others progress more slowly. Therefore, understanding the individual patient’s historical rate of progression is crucial for predicting prognosis.
5. In end-stage ALS, respiratory function and, to a lesser extent, swallowing ability are critical prognostic factors. While respiratory support via artificial ventilation and nutritional support via gastrostomy or other artificial feeding methods can manage these issues, they significantly impact the six-month prognosis. Recurrent aspiration pneumonia, however, can occur even with feeding tubes. The decision to use ventilation or artificial feeding needs careful consideration regarding hospice appropriateness.
6. Neurological examination by a neurologist within three months of hospice assessment is recommended to confirm the ALS diagnosis and assist in establishing a prognosis.

Criteria for Hospice Eligibility in ALS:

Patients with ALS are considered to be in the terminal stage and eligible for hospice if they meet one of the following sets of criteria:

1. Critically Impaired Breathing Capacity: Demonstrated by all of the following within the 12 months preceding initial hospice certification:
   a. Vital capacity (VC) less than 30% of normal (if available).
   b. Dyspnea at rest.
   c. Patient declines mechanical ventilation; external ventilation is used only for comfort.

2. Rapid Progression of ALS and Critical Nutritional Impairment: Demonstrated by all of the following within the 12 months preceding initial hospice certification:
   a. Rapid Progression of ALS:
   i. Progression from independent ambulation to wheelchair to bed-bound status.
   ii. Progression from normal speech to barely intelligible or unintelligible speech.
   iii.Progression from normal diet to pureed diet.
   iv.Progression from independence in most or all activities of daily living (ADLs) to needing major assistance by a caregiver in all ADLs.
   b. Critical Nutritional Impairment:
   i. Oral intake of nutrients and fluids insufficient to sustain life.
   ii. Continuing weight loss.
   iii.Dehydration or hypovolemia.
   iv.Absence of artificial feeding methods intended to sustain life (artificial feeding for comfort is acceptable).

3. Rapid Progression of ALS and Life-Threatening Complications: Demonstrated by both of the following within the 12 months preceding initial hospice certification:
   a. Rapid Progression of ALS: (Same criteria as 2.a. above).
   b. Life-Threatening Complications: Demonstrated by one of the following:
   i. Recurrent aspiration pneumonia (with or without tube feedings).
   ii. Upper urinary tract infection, e.g., pyelonephritis.
   iii.Sepsis.
   iv.Recurrent fever after antibiotic therapy.
   v. Stage 3 or 4 decubitus ulcer(s).

Dementia due to Alzheimer’s Disease and Related Disorders

Criteria for Hospice Eligibility in Dementia:

Patients with dementia due to Alzheimer’s Disease and related disorders are considered to be in the terminal stage when they exhibit all of the following characteristics:

1. Stage seven or beyond according to the Functional Assessment Staging Scale (FAST).
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 ability to speak is limited to six or fewer intelligible words.

AND patients must have experienced one of the following conditions 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 antibiotics.
6. Inability to maintain sufficient fluid and calorie intake with 10% weight loss during the previous six months or serum albumin <2.5 gm/dl.

Note: These criteria are specifically for Alzheimer’s Disease and related disorders and are not applicable to other types of dementia, such as multi-infarct dementia.

Heart Disease

Criteria for Hospice Eligibility in Heart Disease:

Patients with heart disease are considered to be in the terminal stage when they meet the following criteria:

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 implies that if patients are not on vasodilators, there is a documented medical reason for this, such as 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. (NYHA Class IV heart disease is defined by the inability to carry on any physical activity without discomfort. Symptoms of heart failure or angina may be present even at rest, and discomfort increases with any physical activity.) Significant congestive heart failure may be supported by an ejection fraction of ≤20%, but this is not mandatory if not already available.

Documentation of the following factors will support but is not required to establish eligibility for hospice care:

1. Treatment-resistant symptomatic supraventricular or ventricular arrhythmias.
2. History of cardiac arrest or resuscitation.
3. History of unexplained syncope.
4. Brain embolism of cardiac origin.
5. Concomitant HIV disease.

HIV Disease

Criteria for Hospice Eligibility in HIV Disease:

Patients with HIV disease are considered to be in the terminal stage when they meet the following criteria:

1. CD4+ Count <25 cells/µL OR Viral Load >100,000 copies/ml, plus one of the following:
   a. CNS lymphoma.
   b. Untreated, or persistent despite treatment, wasting (loss of at least 10% lean body mass).
   c. Mycobacterium avium complex (MAC) bacteremia, untreated, unresponsive to treatment, or treatment refused.
   d. Progressive multifocal leukoencephalopathy.
   e. Systemic lymphoma, with advanced HIV disease and partial response to chemotherapy.
   f. Visceral Kaposi’s sarcoma unresponsive to therapy.
   g. Renal failure in the absence of dialysis.
   h. Cryptosporidium infection.
   i. Toxoplasmosis, unresponsive to therapy.

2. Decreased performance status, as measured by the Karnofsky Performance Status (KPS) scale, of ≤50%.

Documentation of the following factors will support eligibility for hospice care:

1. Chronic persistent diarrhea for one year.
2. Persistent serum albumin <2.5 gm/dl.
3. Concomitant, active substance abuse.
4. Age >50 years.
5. Absence of, or resistance to effective antiretroviral, chemotherapeutic and prophylactic drug therapy related specifically to HIV disease.
6. Advanced AIDS dementia complex.
7. Toxoplasmosis.
8. Congestive heart failure, symptomatic at rest.
9. Advanced liver disease.

Liver Disease

Criteria for Hospice Eligibility in Liver Disease:

Patients with liver disease are considered to be in the terminal stage when they meet the following criteria:

1. The patient should show both a and b:
   a. Prothrombin time prolonged more than 5 seconds over control, or International Normalized Ratio (INR) >1.5.
   b. Serum albumin <2.5 gm/dl.
2. 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.

Documentation of the following factors will support eligibility for hospice care:

1. Progressive malnutrition.
2. Muscle wasting with reduced strength and endurance.
3. Continued active alcoholism (>80 gm ethanol/day).
4. Hepatocellular carcinoma.
5. HBsAg (Hepatitis B) positivity.
6. Hepatitis C refractory to interferon treatment.

Patients awaiting liver transplant who otherwise fit the above criteria may be certified for the Medicare hospice benefit. However, if a donor organ is procured, the patient should be discharged from hospice.

Pulmonary Disease

Criteria for Hospice Eligibility in Pulmonary Disease:

Patients with pulmonary disease are considered to be in the terminal stage when they meet the following criteria:

1. Severe chronic lung disease as documented by both a and b:
   a. Disabling dyspnea at rest, poorly or unresponsive to bronchodilators, resulting in decreased functional capacity (e.g., bed-to-chair existence, fatigue, and cough). (Documentation of Forced Expiratory Volume in One Second (FEV1), after bronchodilator, less than 30% of predicted is objective evidence for disabling dyspnea, but is not required.)
   b. Progression of end-stage pulmonary disease, as evidenced by increasing visits to the emergency department or hospitalizations for pulmonary infections and/or respiratory failure, or increasing physician home visits prior to initial certification. (Documentation of serial decrease of FEV1 >40 ml/year is objective evidence for disease progression, but is not required.)
2. Hypoxemia at rest on room air, as evidenced by pO2 ≤55 mmHg; or oxygen saturation ≤88%, determined either by arterial blood gases or oxygen saturation monitors. (These values may be obtained from recent hospital records.) OR Hypercapnia, as evidenced by pCO2 ≥50 mmHg. (This value may be obtained from recent [within 3 months] hospital records.)

Documentation of the following factors will support eligibility for hospice care:

1. Right heart failure (RHF) secondary to pulmonary disease (Cor pulmonale) (e.g., not secondary to left heart disease or valvulopathy).
2. Unintentional progressive weight loss of greater than 10% of body weight over the preceding six months.
3. Resting tachycardia >100/min.

Renal Disease

Criteria for Hospice Eligibility in Renal Disease:

Acute Renal Failure:

1. The patient is not seeking dialysis or renal transplant or is discontinuing dialysis.
2. AND either of the following:
   a. Creatinine clearance GFR <10 ml/min (
   b. Serum creatinine >8.0 mg/dl (>6.0 mg/dl for diabetics).

Documentation of the following comorbid conditions will support eligibility for hospice care:

1. Mechanical ventilation.
2. Malignancy (other organ system).
3. Chronic lung disease.
4. Advanced cardiac disease.
5. Advanced liver disease.
6. Sepsis.
7. Immunosuppression/AIDS.
8. Albumin <2.5 gm/dl.
9. Cachexia.
10. Platelet count <25,000.
11. Disseminated intravascular coagulation.
12. Gastrointestinal bleeding.

Chronic Renal Failure:

1. The patient is not seeking dialysis or renal transplant or is discontinuing dialysis.
2. AND either of the following:
   a. Creatinine clearance GFR <15 ml/min (
   b. Serum creatinine >8.0 mg/dl (>6.0 mg/dl for diabetics).

Documentation of the following signs and symptoms of renal failure will support eligibility for hospice care:

1. Uremia.
2. Oliguria <400 ml/24hr.
3. Intractable hyperkalemia (>7.0 mEq/L) not responsive to treatment.
4. Uremic pericarditis.
5. Hepatorenal syndrome.
6. Intractable fluid overload, not responsive to treatment.

Stroke & Coma

Criteria for Hospice Eligibility in Stroke and Coma:

Stroke:

1. Karnofsky Performance Status (KPS) or Palliative Performance Scale (PPS) of 40% or less.
2. Inability to maintain hydration and caloric intake with one of the following:
   a. Weight loss >10% in the last 6 months or >7.5% in the last 3 months.
   b. Serum albumin <2.5 gm/dl.
   c. Current history of pulmonary aspiration not responsive to speech language pathology intervention.
   d. Sequential calorie counts documenting inadequate caloric/fluid intake.
   e. Dysphagia severe enough to prevent the patient from receiving food and fluids necessary to sustain life, in a patient who declines or does not receive artificial nutrition and hydration.

Documentation of diagnostic imaging factors which support poor prognosis after stroke include:

For non-traumatic hemorrhagic stroke:

1. Large-volume hemorrhage on CT:
   a. Infratentorial: ≥20 ml.
   b. Supratentorial: ≥50 ml.
2. Ventricular extension of hemorrhage.
3. Surface area of involvement of hemorrhage ≥30% of cerebrum.
4. Midline shift ≥1.5 cm.
5. Obstructive hydrocephalus in a patient who declines, or is not a candidate for, ventriculoperitoneal shunt.

For thrombotic/embolic stroke:

1. Large anterior infarcts with both cortical and subcortical involvement.
2. Large bihemispheric infarcts.
3. Basilar artery occlusion.
4. Bilateral vertebral artery occlusion.

Coma (any etiology): Comatose patients meeting any 3 of the following on day three of coma:

1. Abnormal brain stem response.
2. Absent verbal response.
3. Absent withdrawal response to pain.
4. Serum creatinine >1.5 mg/dl.

Documentation of the following medical complications, in the context of progressive clinical decline within the previous 12 months, will support a terminal prognosis:

1. Aspiration pneumonia.
2. Upper urinary tract infection (pyelonephritis).
3. Sepsis.
4. Refractory stage 3-4 decubitus ulcers.
5. Fever recurrent after antibiotics.

Conclusion

Determining hospice eligibility is a multifaceted process that goes beyond simply listing diagnoses. It requires a careful evaluation of the patient’s overall clinical condition, disease progression, and specific criteria outlined for various illnesses. These guidelines serve as a framework for healthcare professionals to assess whether a patient has a prognosis of six months or less, making them appropriate for hospice care. The emphasis on thorough documentation, coupled with clinical judgment, ensures that patients who can benefit from hospice services receive timely and appropriate access to this invaluable care option. Understanding these “approved hospice diagnosis list” criteria, as detailed in this article, is essential for ensuring compassionate and effective end-of-life care.