Understanding Diagnosis for Hospice Care: Ensuring Quality End-of-Life Support

Hospice care is a specialized type of healthcare that takes a holistic approach to provide comfort and improve the quality of life for individuals facing a life-limiting illness. This service is delivered by an interdisciplinary team, often under the guidance of a physician medical director who is an expert in hospice and palliative medicine. These physicians often have advanced training and board certification in this subspecialty.

Essentially, hospice care is designed for patients with various advanced illnesses, provided their condition signifies a prognosis of six months or less. The core of hospice is to deliver palliative care, focusing on symptom management and enhancing comfort during the end-of-life journey. Determining appropriate Diagnosis For Hospice Care involves careful consideration. Some chronic conditions might be stable and not significantly impact the patient’s immediate prognosis. Conversely, some treatments for chronic conditions might become burdensome or non-beneficial in the terminal phase. Therefore, a comprehensive evaluation of all conditions, alongside suitable hospice diagnoses and care plans, is essential for each patient.

Research consistently highlights that hospice care improves the quality of life for patients and their families during a very challenging time. However, studies indicate that patients, on average, receive hospice care for only about 2.5 months after being deemed eligible with a six-month prognosis. This statistic often leads to the misunderstanding that hospice care accelerates death. The reality is quite the opposite; it suggests that patients are frequently referred to hospice services much later than when they could have begun benefiting. The fact that eligible individuals are not accessing hospice for the full potential six months of their prognosis means they are missing out on significant support and comfort that hospice can provide. Further research is needed to fully understand the reasons for this delay in hospice enrollment and referral.

Initiating hospice service is more intricate than simply receiving a six-month prognosis from a primary physician. A detailed and meticulous assessment is crucial for a successful transition into hospice. The guidelines, standards, and diagnostic codes related to hospice are continuously evolving, requiring healthcare providers to stay updated. The Centers for Medicare and Medicaid Services (CMS) also frequently updates its regulations regarding billing and coding for hospice services.

Navigating the complexities of hospice diagnoses can be challenging for healthcare professionals who are not specialized in this area. Hospice physicians and organizations play a vital role in offering expertise and clarification. These entities can assist in determining patient eligibility and guide conversations with patients and families to explain the advantages of hospice care. Given the often-complex approval process, early referral to hospice after a terminal diagnosis is generally recommended to ensure seamless and comprehensive care. Ultimately, the hospice organization is accountable for ensuring that all patients meet the eligibility criteria and that the services provided are medically necessary and beneficial.

CMS’s approach to hospice-appropriate diagnoses has evolved, moving from focusing solely on a primary diagnosis to considering all relevant conditions that affect prognosis or the terminal condition itself. The principal diagnosis is defined as the condition primarily responsible for the patient’s need for care and significantly contributing to the six-month prognosis. If multiple diagnoses equally contribute to a poor prognosis, all should be documented as principal diagnoses.

Diagnoses are not static; they can change and require updates throughout the patient’s illness progression. Maintaining an accurate and current list of diagnoses is vital. Stagnant diagnoses might incorrectly suggest a stable condition, potentially leading to a re-evaluation of hospice eligibility when continued care is still needed and appropriate.

Determining a terminal prognosis of six months or less often involves considering multiple hospice-appropriate diagnoses. All diagnoses must be confirmed and documented by a physician or authorized provider who assumes legal responsibility for the patient’s diagnostic assessment.[¹][²][³][⁴]

Key Concerns in Hospice Diagnosis

Many concerns surrounding hospice-appropriate diagnoses are linked to obtaining and maintaining approvals, as well as navigating billing and coding accurately. Common challenges include the effective use of symptom codes, combination codes, and correctly coding diagnoses that may not be explicitly listed in standard manuals. Emerging areas of concern involve specific conditions like dementia (clarifying ambiguities in diagnosis), fractures as primary diagnoses, the proper sequencing of primary versus secondary cancers, and the accurate coding of cerebrovascular diseases, especially distinguishing between acute and late effects.[⁵][⁶]

Clinical Importance of Accurate Diagnosis in Hospice

Each patient’s situation is unique, and various diagnoses and conditions can influence their care in the final stages of life. Documentation should be thorough, clear, and factual, reflecting the patient’s specific circumstances and how their diagnoses impact their prognosis. Regular reassessment of the patient’s condition is crucial to ensure continued hospice appropriateness, considering their physical, psychological, social, and spiritual needs. CMS mandates the coding of all active diagnoses in the patient’s records. Consequently, past diagnoses that no longer affect the patient’s current status or prognosis (history codes) should be removed according to coding guidelines. 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 be addressed within the narrative section of the care plan documentation. The process of hospice enrollment and determining appropriate diagnoses demands critical clinical judgment from the physician. This includes maintaining an updated list of conditions and removing irrelevant history codes when necessary.

For reference, the following are abridged assessment criteria from the Centers for Medicare and Medicaid Services regarding disease progression and non-disease-specific baseline guidelines:

Part 1: Guidelines for Decline in Clinical Status

A. Disease Progression Indicated by Worsening Status, Symptoms, Signs, and Laboratory Results:

Clinical Status

• Recurrent or treatment-resistant infections
• Progressive wasting (inanition) documented by measures such as 10% weight loss, decreased albumin levels, and dysphagia leading to aspiration risks.

Symptoms

• A range of symptoms including persistent nausea and vomiting, dyspnea (shortness of breath), chronic cough, fatigue, cognitive decline, diarrhea, and increasing pain.

Signs

• Clinical signs such as hypotension (low blood pressure), edema (swelling), ascites (fluid in the abdomen), progressive weakness, and new or worsening altered mental status.

Laboratory Results

• Deteriorating laboratory findings, including worsening pCO2/pO2/SaO2 levels (blood gas abnormalities), declining liver function tests, increasing tumor markers, and unstable sodium and potassium levels.

B. Progressive disease leading to a decline in Karnofsky Performance Status or Palliative Performance Score.[⁷]

C. Advancement in functional assessment staging of dementia.

D. Increased need for assistance with Activities of Daily Living (ADLs).

E. Development or worsening of refractory stage 3 or 4 pressure ulcers despite optimal wound care.

F. Increased healthcare utilization, such as emergency room visits, hospitalizations, 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 of functional status, indicated by a Karnofsky Performance Status or Palliative Performance Score below 70%.

B. Requirement of assistance for two or more Activities of Daily Living (ADLs): including ambulation, transferring, dressing, feeding, continence, and bathing.

C. Comorbidities: When conditions other than the primary diagnosis contribute significantly to a prognosis of six months or less, they should be considered. These can include[⁸][⁹][¹⁰][¹¹]:

• Chronic Obstructive Pulmonary Disease (COPD)
• Congestive Heart Failure (CHF)
• Ischemic Heart Disease
• Diabetes Mellitus
• Neurological Diseases (e.g., cerebrovascular accident, Parkinson’s disease, multiple sclerosis, amyotrophic lateral sclerosis)
• Renal Failure
• Liver Disease
• Cancer (Neoplasia)
• Acquired Immunodeficiency Syndrome/HIV
• Dementia
• Refractory severe autoimmune diseases (e.g., lupus or rheumatoid arthritis)
• Recurrent sepsis

Review Questions

(Note: Review questions from the original article are omitted as per instructions.)

References

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Disclosures: Dac Teoli declares no relevant financial relationships with ineligible companies.

Disclosures: Abhishek Bhardwaj declares no relevant financial relationships with ineligible companies.