Hospice care is a specialized type of healthcare that focuses on providing comprehensive comfort and support to patients and their families facing a life-limiting illness. Rooted in a holistic approach, hospice aims to enhance the quality of life for individuals with a prognosis of six months or less. Typically delivered by an interdisciplinary team under the guidance of a hospice physician, this care model addresses physical, emotional, social, and spiritual needs. Many hospice physicians pursue specialized training and board certification in hospice and palliative medicine to expertly manage the complex needs of these patients.
While numerous conditions could potentially qualify a patient for hospice, the core principle is to offer palliative and symptomatic relief when curative treatments are no longer effective or aligned with the patient’s goals. Determining hospice eligibility involves a thorough evaluation of a patient’s overall health status, considering all existing diagnoses and their impact on prognosis. It’s crucial to differentiate between chronic stable conditions and those that significantly contribute to a limited life expectancy. Some treatments, while beneficial for chronic conditions, might become burdensome or futile in the terminal phase of illness. Therefore, a holistic assessment is necessary to identify hospice-appropriate diagnoses and tailor care plans accordingly.
Research consistently demonstrates that hospice care improves the quality of life for patients facing terminal illnesses. However, studies also reveal a concerning trend: patients often enroll in hospice care much later than they are eligible. The average length of hospice care is around 2.5 months, despite the eligibility criterion being a six-month prognosis. This delay suggests that many individuals are missing out on the full spectrum of benefits that hospice services can offer during their final months. Further investigation is needed to understand the reasons behind this delayed access, but it highlights the importance of early identification and referral to hospice for eligible patients.
The process of hospice enrollment is more nuanced than simply having a primary physician declare a prognosis of fewer than six months. A meticulous assessment and documentation are essential for a smooth transition into hospice care. The evolving landscape of healthcare guidelines, coding systems like ICD codes, and regulations from bodies like the Centers for Medicare & Medicaid Services (CMS) continuously shape the interpretation and application of hospice diagnoses and eligibility criteria. Staying updated with these changes, particularly concerning billing and coding expectations, is crucial for healthcare providers.
For healthcare professionals who may find navigating the complexities of hospice diagnoses challenging, hospice organizations and physicians specializing in palliative care offer invaluable support. These entities can assist in determining patient eligibility and provide guidance through the often-intricate approval process. Furthermore, hospice teams are skilled in facilitating sensitive conversations with patients and families to explain the benefits of hospice care. Early referral after a terminal diagnosis is recognized as a best practice, ensuring seamless integration of comprehensive and longitudinal end-of-life care. Ultimately, hospice agencies bear the responsibility for ensuring that all patients under their care meet hospice eligibility criteria and that the services provided are medically necessary and aligned with patient needs.
CMS’s approach to hospice-appropriate diagnoses has evolved, moving from a focus solely on a primary diagnosis to a more inclusive consideration of all relevant conditions impacting prognosis. The primary hospice diagnosis is generally understood as the condition most significantly contributing to the patient’s six-month prognosis, similar to the “principal diagnosis” defined in hospital discharge data sets. In cases where multiple hospice-appropriate diagnoses equally contribute to a poor prognosis, all should be documented as principal diagnoses. The order of these diagnoses is not relevant.
Diagnoses in hospice care are not static. They can change and require ongoing documentation as a patient’s condition progresses through the terminal stages. Maintaining an updated and accurate list of diagnoses is essential. Conversely, keeping diagnoses unchanged over time might inaccurately suggest patient stability, potentially raising questions about continued hospice eligibility. Regular re-evaluation is therefore crucial.
Determining a terminal prognosis of six months or less often involves considering multiple hospice-appropriate diagnoses. All diagnoses contributing to hospice eligibility must be confirmed and documented by a physician or authorized provider who assumes legal responsibility for the patient’s diagnoses.
Key Concerns in Hospice Diagnosis
Many concerns surrounding hospice-appropriate diagnoses center on securing and maintaining hospice approval, along with navigating billing and coding requirements. Common challenges include the appropriate use of symptom codes, combination codes, and accurately coding diagnoses not explicitly listed in standard manuals. Specific diagnostic categories that often raise questions include dementia, fractures as primary diagnoses, sequencing of primary and secondary cancers, and the differentiation between acute and late effects of cerebrovascular conditions. Clear and consistent documentation is essential to address these potential ambiguities.
Clinical Significance of Accurate Hospice Diagnosis
Each hospice patient is unique, and their individual diagnoses and conditions profoundly shape their end-of-life care journey. Documentation must be comprehensive, clear, and factual, reflecting the patient’s specific circumstances and the impact of their diagnoses on their prognosis. Regular re-evaluation of the patient’s status is crucial to ensure continued appropriateness for hospice care, considering their physical, mental, social, and spiritual well-being. CMS guidelines emphasize coding all current diagnoses in the patient’s documentation. Diagnoses from the past that no longer affect the patient’s current status or prognosis (“history codes”) should be removed according to coding guidelines to maintain clarity and accuracy. Hospice claims can accommodate up to twenty-five diagnoses. If certain conditions lack specific codes or cannot be included in the diagnosis section, they can still be documented and considered within the narrative plan of care. Enrolling patients in hospice and accurately determining hospice-appropriate diagnoses demands critical thinking from physicians. This includes maintaining a current and relevant list of conditions and removing outdated history codes when necessary to reflect the patient’s present health status.
For practical guidance, CMS outlines assessment criteria for disease progression and non-disease-specific baseline guidelines to aid in determining hospice eligibility. These guidelines include:
Part 1: Decline in Clinical Status Guidelines
A. Progression of Disease: Evidenced by worsening status, symptoms, signs, and laboratory results:
* **Clinical Status:** Recurrent infections, progressive inanition (e.g., weight loss, decreased albumin, dysphagia).
* **Symptoms:** Nausea, vomiting, dyspnea, persistent cough, fatigue, cognitive decline, diarrhea, progressive pain.
* **Signs:** Hypotension, edema, ascites, progressive weakness, new altered mental status.
* **Laboratory Results:** Worsening blood gas values (pCO2/pO2/SaO2), liver function tests, tumor markers, and electrolyte imbalances (sodium, potassium).B. Functional Decline: Progressive disease leading to a decline in Karnofsky Performance Status (KPS) or Palliative Performance Scale (PPS).
C. Dementia Progression: Worsening functional assessment staging of diagnosed dementia.
D. Increased Dependence in ADLs: Requiring assistance with additional Activities of Daily Living (ADLs).
E. Pressure Ulcers: Worsening refractory stage 3 or 4 pressure ulcers despite optimal wound care.
F. Increased Healthcare Utilization: Increased emergency room visits, hospital admissions, and physician appointments related to the primary hospice diagnosis prior to hospice enrollment.
Part 2: Non-Disease Specific Baseline Guidelines (Both A and B must be met)
A. Physiological Impairment: Karnofsky Performance Status or Palliative Performance Score of less than 70%.
B. Assistance with ADLs: Needing assistance with two or more ADLs (ambulation, transfer, dressing, feeding, continence, bathing).
C. Comorbidities: Presence of significant comorbidities that contribute to a prognosis of 6 months or less, even if not the primary hospice diagnosis. Examples include:
* Chronic Obstructive Pulmonary Disease (COPD)
* Congestive Heart Failure (CHF)
* Ischemic Heart Disease
* Diabetes Mellitus
* Neurologic Diseases (stroke, Parkinson's, MS, ALS)
* Renal Failure
* Liver Disease
* Cancer (Neoplasia)
* HIV/AIDS
* Dementia
* Refractory Severe Autoimmune Diseases (lupus, rheumatoid arthritis)
* Recurrent SepsisReview Questions
[Original review questions section would be included here if needed, but not provided in the source text, so omitted as per instructions.]
References
[List of references as provided in the original text, ensuring all links are functional and correctly formatted in markdown.]
1.Buss MK, Rock LK, McCarthy EP. Understanding Palliative Care and Hospice: A Review for Primary Care Providers. Mayo Clin Proc. 2017 Feb;92(2):280-286. [PubMed: 28160875]
2.Wallace CL. Examining hospice enrollment through a novel lens: Decision time. Palliat Support Care. 2017 Apr;15(2):168-175. [PubMed: 27407060]
3.Wang X, Knight LS, Evans A, Wang J, Smith TJ. Variations Among Physicians in Hospice Referrals of Patients With Advanced Cancer. J Oncol Pract. 2017 May;13(5):e496-e504. [PMC free article: PMC5455161] [PubMed: 28221897]
4.Cheraghlou S, Gahbauer EA, Leo-Summers L, Stabenau HF, Chaudhry SI, Gill TM. Restricting Symptoms Before and After Admission to Hospice. Am J Med. 2016 Jul;129(7):754.e7-754.e15. [PMC free article: PMC4914433] [PubMed: 26968471]
5.Dolin R, Hanson LC, Rosenblum SF, Stearns SC, Holmes GM, Silberman P. Factors Driving Live Discharge From Hospice: Provider Perspectives. J Pain Symptom Manage. 2017 Jun;53(6):1050-1056. [PubMed: 28323079]
6.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. Am J Hosp Palliat Care. 2017 Sep;34(8):748-753. [PubMed: 27443281]
7.Mehta A, Chai E, Berglund K, Rizzo E, Moreno J, Gelfman LP. Using Admission Karnofsky Performance Status as a Guide for Palliative Care Discharge Needs. J Palliat Med. 2021 Jun;24(6):910-913. [PMC free article: PMC8336248] [PubMed: 33524302]
8.Jones BW. Evidence-based practice in hospice: is qualitative more appropriate than quantitative? Home Healthc Nurse. 2013 Apr;31(4):184-8. [PubMed: 23549249]
9.Kaufman BG, Klemish D, Kassner CT, Reiter JP, Li F, Harker M, O’Brien EC, Taylor DH, Bhavsar NA. Predicting Length of Hospice Stay: An Application of Quantile Regression. J Palliat Med. 2018 Aug;21(8):1131-1136. [PubMed: 29762075]
10.Goy ER, Bohlig A, Carter J, Ganzini L. Identifying predictors of hospice eligibility in patients with Parkinson disease. Am J Hosp Palliat Care. 2015 Feb;32(1):29-33. [PubMed: 23975684]
11.Wladkowski SP, Wallace CL. Current Practices of Live Discharge from Hospice: Social Work Perspectives. Health Soc Work. 2019 Feb 01;44(1):30-38. [PubMed: 30561640]
Disclosure: Dac Teoli declares no relevant financial relationships with ineligible companies.
Disclosure: Abhishek Bhardwaj declares no relevant financial relationships with ineligible companies.
