CMS Criteria for Renal Failure as Diagnosis for Hospice Care

Understanding CMS Guidelines for Hospice Eligibility in Renal Failure

Navigating the end-of-life journey for individuals with renal failure requires compassionate care and a clear understanding of eligibility for hospice benefits. The Centers for Medicare & Medicaid Services (CMS) has established specific criteria to determine when renal failure qualifies as a terminal illness, making patients eligible for hospice care. This article delves into the CMS criteria for renal failure as a diagnosis for hospice, providing a comprehensive guide for healthcare professionals, caregivers, and anyone seeking to understand these crucial guidelines.

Hospice care under Medicare is designed to provide comfort and support to individuals with a life expectancy of six months or less if their terminal illness runs its normal course. The determination of hospice eligibility is based on a physician’s clinical judgment, supported by clinical documentation that reflects the patient’s current health status and anticipated disease progression. While these guidelines offer a framework, it’s important to remember that they are intended to assist in – not dictate – hospice eligibility decisions. Each patient’s situation is unique, and comprehensive documentation is key to ensuring appropriate access to hospice benefits.

General Hospice Eligibility Criteria: Decline in Clinical Status (Part I Guidelines)

CMS guidelines outline a two-pronged approach to determining hospice eligibility. The first, Part I, focuses on a decline in clinical status, applicable across all diagnoses. This section emphasizes documented evidence of a patient’s deteriorating condition, indicating a life expectancy of six months or less. It’s crucial to note that these indicators must reflect irreversible decline, not temporary setbacks.

Here are the key clinical status decline guidelines:

Progression of Disease: This is evidenced by worsening clinical status, symptoms, signs, and laboratory results. Specific indicators include:
- Clinical Status:
  - Recurrent or intractable serious infections like pneumonia, sepsis, or pyelonephritis.
  - Progressive inanition (severe nutritional deficiency) documented by:
    - Unintentional weight loss of 10% or more of body weight within the preceding six months, not attributable to reversible causes such as depression or diuretics.
    - Decreasing anthropomorphic measurements (mid-arm circumference, abdominal girth), excluding reversible causes.
    - Observable signs of weight loss like ill-fitting clothes, decreased skin turgor, or increased skin folds in the absence of documented weight.
    - Declining serum albumin or cholesterol levels.
    - Dysphagia (difficulty swallowing) leading to recurrent aspiration and/or inadequate oral intake, evidenced by reduced food portion consumption.
- Symptoms:
  - Dyspnea (shortness of breath) with increasing respiratory rate.
  - Intractable cough.
  - Nausea and vomiting poorly responsive to treatment.
  - Intractable diarrhea.
  - Pain requiring escalating doses of strong analgesics beyond brief periods.
- Signs:
  - Decrease in systolic blood pressure below 90 mmHg or progressive postural hypotension.
  - Ascites (fluid accumulation in the abdomen).
  - Venous, arterial, or lymphatic obstruction due to disease progression or metastasis.
  - Edema (swelling).
  - Pleural or pericardial effusion (fluid around the lungs or heart).
  - Weakness.
  - Changes in level of consciousness.
- Laboratory Findings (When Available): While not mandatory for hospice eligibility, lab results can provide supporting evidence:
  - Increasing pCO2, decreasing pO2, or decreasing SaO2 (indicating respiratory compromise).
  - Elevated calcium, creatinine, or liver function tests (indicating organ dysfunction).
  - Increasing tumor markers (e.g., CEA, PSA, if applicable).
  - Progressively decreasing or increasing serum sodium or increasing serum potassium (electrolyte imbalances).
Decline in Functional Status: A progressive decline in Karnofsky Performance Status (KPS) or Palliative Performance Score (PPS) due to disease progression is a significant indicator. These scales measure a patient’s functional abilities and overall well-being. (These scales are detailed at the end of this article for reference.)
Progressive Decline in Functional Assessment Staging (FAST) for Dementia: For patients with dementia, a progression from stage 7A onwards on the FAST scale signifies terminal decline. (The FAST scale is detailed at the end of this article for reference.)
Progression to Dependence in Activities of Daily Living (ADLs): Increasing dependence on assistance with ADLs such as ambulation, continence, transferring, dressing, feeding, and bathing points to declining functional capacity. (ADLs are listed in Part II, Section 2 of the original document and further detailed below.)
Progressive Stage 3-4 Pressure Ulcers: Despite optimal care, the development or worsening of stage 3 or 4 pressure ulcers suggests significant underlying frailty and poor prognosis.
History of Increasing Healthcare Utilization: An increasing pattern of Emergency Room visits, hospitalizations, or physician visits related to the primary hospice diagnosis prior to electing hospice benefits can indicate disease progression and instability.

Non-Disease Specific Baseline Guidelines (Part II Guidelines)

Part II of the CMS guidelines outlines non-disease-specific baseline guidelines. These criteria, in conjunction with disease-specific guidelines (Part III), help establish hospice eligibility. Both sections A and B of Part II should be met.

Physiologic Impairment of Functional Status: This is demonstrated by a reduced Karnofsky Performance Status (KPS) or Palliative Performance Score (PPS). Lower scores on these scales indicate greater functional impairment.
Dependence on Assistance for Two or More Activities of Daily Living (ADLs): Requiring assistance with at least two of the following ADLs signifies a significant level of functional decline:
- Ambulation (walking)
- Continence (bladder and bowel control)
- Transfer (moving from bed to chair, etc.)
- Dressing
- Feeding
- Bathing
Co-morbidities: While not the primary hospice diagnosis, the presence and severity of co-existing conditions can significantly contribute to a prognosis of six months or less. These comorbidities should be considered in the overall hospice eligibility determination. Examples of such conditions include:
- Chronic obstructive pulmonary disease (COPD)
- Congestive heart failure (CHF)
- Ischemic heart disease
- Diabetes mellitus
- Neurologic diseases (e.g., CVA, ALS, MS, Parkinson’s)
- Renal failure
- Liver disease
- Neoplasia (cancer)
- Acquired immune deficiency syndrome (AIDS)/HIV
- Dementia
- Refractory severe autoimmune diseases (e.g., Lupus, Rheumatoid Arthritis)

It is important to note that these baseline guidelines alone do not qualify a patient for hospice coverage. They are meant to be used in conjunction with either the “Decline in Clinical Status” guidelines (Part I) or the disease-specific guidelines (Part III).

Disease-Specific Guidelines: Renal Disease (Part III Guidelines)

Part III of the CMS guidelines provides disease-specific guidelines, which are used in conjunction with the Non-disease specific baseline guidelines (Part II). For renal disease, there are separate criteria for acute and chronic renal failure.

Acute Renal Failure Criteria

For acute renal failure, the following criteria apply: (Criterion 1 and either 2, 3, or 4 should be present, and factors from 5 provide supporting documentation.)

Dialysis Decision: The patient is not seeking dialysis or renal transplantation, or is discontinuing dialysis. While patients on dialysis can elect hospice, the continuation of dialysis significantly alters prognosis and may impact hospice eligibility. If a patient elects hospice for end-stage renal disease (ESRD) or a condition related to the need for dialysis, the hospice is financially responsible for dialysis. Medicare hospice reimbursement is a per diem rate, and there is no additional reimbursement for dialysis in these cases. Dual benefit access (hospice and ESRD benefits) is only possible when the need for dialysis is unrelated to the terminal illness.
Creatinine Clearance: Creatinine clearance is <10 ml/min (or <15 ml/min for diabetics). Creatinine clearance is a measure of kidney function, reflecting the rate at which creatinine is filtered from the blood by the kidneys. Lower creatinine clearance indicates poorer kidney function.
Serum Creatinine: Serum creatinine is > 8.0 mg/dl (>6.0 mg/dl for diabetics). Serum creatinine is another blood test used to assess kidney function. Elevated serum creatinine levels suggest impaired kidney function.
Estimated Glomerular Filtration Rate (GFR): GFR is <15 ml/min/1.73 m2 (or <20 ml/min/1.73 m2 for diabetics). GFR is considered the best overall index of kidney function. It estimates how much blood the kidneys filter each minute. Lower GFR values indicate reduced kidney function.
Comorbid Conditions (Supporting Documentation): The presence of the following comorbid conditions can lend further support to hospice eligibility in acute renal failure:
- Mechanical ventilation
- Malignancy (other organ system)
- Chronic lung disease
- Advanced cardiac disease
- Advanced liver disease
- Immunosuppression/AIDS
- Serum albumin <3.5 gm/dl (low protein level, indicating poor nutritional status and overall health)
- Platelet count <25,000/mm3 (low platelet count, indicating potential bleeding risk and bone marrow suppression)
- Disseminated intravascular coagulation (DIC) (a serious blood clotting disorder)
- Gastrointestinal bleeding

Chronic Kidney Disease Criteria

For chronic kidney disease, the criteria are similar to acute renal failure: (Criterion 1 and either 2, 3, or 4 should be present, and factors from 5 provide supporting documentation.)

Dialysis Decision: The patient is not seeking dialysis or renal transplantation, or is discontinuing dialysis. The same considerations regarding dialysis and hospice eligibility as outlined in acute renal failure apply here.
Creatinine Clearance: Creatinine clearance is <10 ml/min (or <15 ml/min for diabetics).
Serum Creatinine: Serum creatinine is > 8.0 mg/dl (>6.0 mg/dl for diabetics).
Signs and Symptoms of Renal Failure: The presence of the following signs and symptoms of renal failure, particularly if intractable or unresponsive to treatment, supports hospice eligibility:
- Uremia (a toxic condition caused by buildup of waste products in the blood due to kidney failure)
- Oliguria (urine output <400 ml/24 hours) or Anuria (urine output <100 ml/24 hours) – reduced or absent urine production.
- Intractable hyperkalemia (> 7.0 mEq/L) not responsive to treatment – dangerously high potassium levels resistant to medical management.
- Uremic pericarditis (inflammation of the sac surrounding the heart due to uremia).
- Hepatorenal syndrome (kidney failure occurring in the context of severe liver disease).
- Intractable fluid overload, not responsive to treatment – fluid retention that cannot be managed with standard medical therapies.
Estimated Glomerular Filtration Rate (GFR): GFR is <15 ml/min/1.73 m2 (or <20 ml/min/1.73 m2 for diabetics).

Key Considerations for Renal Failure and Hospice Eligibility

Clinical Judgment is Paramount: While these guidelines provide specific parameters, the physician’s clinical judgment remains central to determining hospice eligibility. The guidelines are intended to support, not replace, professional medical assessment.
Comprehensive Documentation: Meticulous documentation is essential to justify hospice eligibility, especially when a patient’s presentation doesn’t perfectly align with specific guidelines. This documentation should include a detailed medical history, current clinical status, disease trajectory, and rationale for a six-month or less prognosis.
Comorbidities Matter: In renal failure, as with other conditions, comorbidities play a significant role in prognosis. The presence of conditions like heart failure, diabetes, or liver disease can worsen the prognosis for patients with renal failure and should be carefully considered.
Dialysis and Hospice: Patients choosing hospice care for renal failure are generally not pursuing or are discontinuing dialysis, as dialysis can significantly prolong life. However, the guidelines acknowledge that patients on dialysis can be eligible for hospice if their prognosis remains six months or less, and the hospice assumes financial responsibility for dialysis in such cases when the need for dialysis is related to the terminal condition.

Conclusion

The CMS criteria for renal failure as a diagnosis for hospice care offer a detailed framework for determining eligibility for individuals with end-stage kidney disease. By understanding these guidelines, healthcare providers can ensure that patients with renal failure who meet the criteria for a terminal prognosis have access to the compassionate and comprehensive care that hospice provides. Remember that these guidelines are designed to aid in clinical decision-making and should always be applied with careful consideration of each patient’s unique clinical picture and circumstances.

(Note: The following scales are for reference and were mentioned in the original document.)

Karnofsky Performance Scale (KPS)

Rating (%)	Criteria
100	Normal, no complaints, no evidence of disease.
90	Able to carry on normal activity; minor signs or symptoms of disease.
80	Normal activity with effort; some signs or symptoms of disease.
70	Cares for self; unable to carry on normal activity or to do active work.
60	Requires occasional assistance, but is able to care for most personal needs.
50	Requires considerable assistance and frequent medical care.
40	Disabled; requires special care and assistance.
30	Severely disabled; hospital admission is indicated although death not imminent.
20	Very sick; hospital admission necessary; active supportive treatment necessary.
10	Moribund; fatal processes progressing rapidly.
0	Dead

Palliative Performance Scale (PPS)

PPS Level	Ambulation	Activity & Evidence of Disease	Self-Care	Intake	Conscious Level
100%	Full	Normal activity & work No evidence of disease	Full	Normal	Full
90%	Full	Normal activity & work Some evidence of disease	Full	Normal	Full
80%	Full	Normal activity with effort Some evidence of disease	Full	Normal or reduced	Full
70%	Reduced	Unable Normal Job/Work Significant disease	Full	Normal or reduced	Full
60%	Reduced	Unable hobby/house work Significant disease	Occasional assistance necessary	Normal or reduced	Full or Confusion
50%	Mainly Sit/Lie	Unable to do any work Extensive disease	Considerable assistance required	Normal or reduced	Full or Confusion
40%	Mainly in Bed	Unable to do most activity Extensive disease	Mainly assistance	Normal or reduced	Full or Drowsy +/- Confusion
30%	Totally Bed Bound	Unable to do any activity Extensive disease	Total Care	Normal or reduced	Full or Drowsy +/- Confusion
20%	Totally Bed Bound	Unable to do any activity Extensive disease	Total Care	Minimal to sips	Full or Drowsy +/- Confusion
10%	Totally Bed Bound	Unable to do any activity Extensive disease	Total Care	Mouth care only	Drowsy or Coma +/- Confusion
0%	Death	–	–	–	–

Functional Assessment Staging (FAST) Scale for Alzheimer’s Disease

| FAST Scale Stage | Characteristics – CMS Criteria for Chronic Kidney Disease

CMS Criteria for Acute Renal Failure
Hospice Eligibility for Renal Failure
Renal Failure and Hospice Care: A Comprehensive Guide
Understanding Hospice Qualifications for Renal Failure
Navigating Hospice with Renal Failure: CMS Guidelines Explained
Renal Failure as a Terminal Illness: Meeting Hospice Criteria
Qualifying for Hospice with Kidney Disease: What You Need to Know
Hospice Admission for Renal Failure: CMS Eligibility Requirements
CMS Hospice Benefit and Renal Failure: A Detailed Overview