Hospice care stands as a vital medical service, employing a holistic approach to enhance the quality of life for individuals nearing the end of life. This specialized care model is delivered by an interprofessional team, often under the guidance of a physician medical director who possesses advanced training and board certification in hospice and palliative medicine. For those navigating serious illness, understanding what constitutes a “Hospice Appropriate Diagnosis” is paramount.
Essentially, many conditions can become hospice-appropriate diagnoses as they progress. Hospice fundamentally aims to provide palliative care and manage complex symptoms for patients with a life expectancy of six months or less. Determining hospice eligibility requires careful consideration. Some chronic conditions, while present, might not significantly impact a patient’s immediate prognosis. Furthermore, aggressive treatments for certain chronic illnesses may become detrimental in the terminal stages, contrasting with the goals of palliative care. Therefore, a comprehensive evaluation of all conditions, alongside hospice-appropriate diagnoses and treatment plans, is essential for each patient.
Research consistently underscores the positive impact of hospice on patients’ quality of life. However, statistics reveal a critical gap: hospice patients, on average, live only about 2.5 months after receiving a six-month prognosis and enrolling in services. This statistic highlights a significant issue – patients often access hospice care later than they become eligible. The reality is that while hospice is designed for individuals with a prognosis of six months or less, many patients do not begin receiving these services until much closer to death. This delay means patients are missing out on the comprehensive benefits hospice care can offer during a potentially longer period. Further investigation is needed to understand the reasons behind this delayed access, but it’s clear that earlier referrals could significantly improve the end-of-life experience for many.
Enrolling in hospice care involves more than just a physician’s prognosis of a life expectancy under six months. Numerous factors require meticulous assessment and documentation to ensure a smooth transition into hospice. The landscape of hospice diagnoses and regulations is constantly evolving, influenced by new guidelines, revised standards, and updated ICD codes. Similarly, the Centers for Medicare and Medicaid Services (CMS) continually updates its expectations regarding billing and coding practices.
Navigating the complexities of hospice-appropriate diagnoses can be challenging for healthcare providers who are not consistently engaged with the latest literature. This is where hospice physicians and organizations play a crucial role, offering valuable expertise and guidance. Hospice organizations are equipped to assist in determining patient eligibility and can facilitate sensitive conversations with patients and families about the advantages of hospice services. Given the intricate approval process, early referral to hospice services following a terminal diagnosis is generally encouraged to foster seamless and comprehensive longitudinal care. Ultimately, hospice agencies bear the responsibility for ensuring all patients under their care meet hospice eligibility criteria and that services provided are medically necessary.
CMS has progressively refined its approach to hospice-appropriate diagnoses. A significant shift has been the move away from focusing solely on a primary hospice diagnosis. The current emphasis is on considering all relevant conditions, related or unrelated to the primary diagnosis, that affect a patient’s prognosis or underlying terminal condition. The Uniform Hospital Discharge Data Set defines the principal diagnosis as the “condition after study chiefly responsible for occasioning admission of the patient to the hospital.” In the context of hospice, the principal diagnosis is understood as the condition most significantly contributing to the patient’s six-month prognosis. If multiple hospice-appropriate diagnoses equally contribute to a poor prognosis, all should be documented as principal diagnoses, without a required sequence.
Diagnoses are not static; they evolve as a patient’s condition progresses through the terminal stages. Changes in diagnoses, including additions and removals, must be documented to accurately reflect the patient’s current health status. Maintaining static diagnoses over time could misrepresent the patient’s condition as stable, potentially leading to an inaccurate assessment of their continued hospice appropriateness.
Determining a patient’s terminal prognosis, with a life expectancy of six months or less, often involves considering multiple hospice-appropriate diagnoses. All diagnoses must be confirmed by a physician or legally authorized provider responsible for establishing the patient’s medical diagnoses.[1][2][3][4]
Key Concerns Regarding Hospice Appropriate Diagnoses
The primary concerns surrounding hospice-appropriate diagnoses center on securing and maintaining hospice approval, alongside navigating the complexities of billing and coding. Frequently encountered challenges include the correct utilization of symptom codes, combination codes, and accurately coding diagnoses not explicitly listed in standard manuals. Emerging areas of concern involve specific diagnoses, such as the nuances of dementia diagnoses, establishing fractures as primary diagnoses, proper sequencing of primary versus secondary neoplasms, and accurate documentation of cerebrovascular conditions, differentiating between acute and late-effect codes.[5][6]
Clinical Significance and Holistic Patient Assessment
Each patient’s journey through serious illness is unique, necessitating a personalized approach to hospice care. Numerous diagnoses and conditions can influence care during the final stages of life. Comprehensive, clear, and factual documentation is crucial, detailing the patient’s circumstances and the impact of their diagnoses on their prognosis. Regular reassessment of the patient’s continued suitability for hospice care is essential, considering their physical, mental, social, and spiritual needs.
CMS mandates the coding of all current diagnoses in patient documentation. Consequently, historical diagnoses that no longer impact the patient’s present condition or prognosis (history codes) should be removed according to coding guidelines. Hospice claims can accommodate up to twenty-five diagnoses. For conditions lacking specific codes or those that cannot be included in the diagnosis section, coverage can be justified within the narrative section of the plan of care documentation. Effectively navigating hospice enrollment and determining hospice-appropriate diagnoses requires critical clinical reasoning from the physician. This includes maintaining an updated list of conditions and removing irrelevant history codes when appropriate.
For practical guidance, the Centers for Medicare and Medicaid Services outlines assessment criteria for disease progression and non-disease-specific baseline guidelines. An abridged version of these criteria is presented below:
Part 1: Decline in a Patient’s Clinical Status Guidelines
A. Progression of disease indicated by worsening status, symptoms, signs, and laboratory results:
-
Clinical Status:
- Refractory or recurring infections
- Progressive inanition (documented by measures like 10% body weight loss, decreased albumin, dysphagia leading to aspiration)
-
Symptoms:
- Nausea and vomiting
- Dyspnea
- Persistent cough
- Fatigue
- Decreased cognition
- Diarrhea
- Progressive pain
-
Signs:
- Hypotension
- Edema
- Ascites
- Progressive weakness
- New altered mental status
-
Laboratory Results:
- Worsening pCO2/pO2/SaO2 values
- Worsening liver function tests
- Worsening tumor markers
- Volatile sodium and potassium levels
B. Progressive disease leading to a worsened Karnofsky Performance Status or Palliative Performance Score.[7]
C. Worsened functional assessment staging of diagnosed dementia.
D. Requirement for assistance with additional Activities of Daily Living (ADLs).
E. Worsening refractory stage 3 to stage 4 pressure ulcers despite optimal wound care.
F. Increased healthcare utilization in the form of emergency department visits, hospital admissions, and physician appointments related to the primary hospice diagnosis before hospice enrollment.
Part 2: Non-Disease Specific Baseline Guidelines (Both points A and B must be met).
A. Physiologic impairment of functional status as indicated by a Karnofsky Performance Status or Palliative Performance Score of less than 70 percent.
B. Need for assistance with greater than or equal to two Activities of Daily Living (ADLs) including: ambulation, transfer, dressing, feeding, continence, and bathing.
C. Comorbidities: In cases where a condition is not the primary hospice diagnosis, the presence of significant comorbid diseases contributing to a prognosis of six months or less should be considered. Examples include:[8][9][10][11]
- Chronic obstructive pulmonary disease (COPD)
- Congestive heart failure (CHF)
- Ischemic heart disease
- Diabetes mellitus
- Neurologic diseases (cerebrovascular accident, Parkinson’s disease, multiple sclerosis, amyotrophic lateral sclerosis)
- Renal failure
- Liver disease
- Neoplasia
- Acquired immune deficiency syndrome/HIV
- Dementia
- Refractory severe autoimmune diseases (e.g., lupus, rheumatoid arthritis)
- Recurrent sepsis
Conclusion
Accurately determining and documenting hospice-appropriate diagnoses is a cornerstone of effective end-of-life care. It requires a thorough understanding of evolving guidelines, a commitment to holistic patient assessment, and diligent clinical reasoning. By prioritizing these aspects, healthcare professionals can ensure patients receive timely and appropriate hospice services, maximizing their quality of life during their final months.
References
- 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]
- Wallace CL. Examining hospice enrollment through a novel lens: Decision time. Palliat Support Care. 2017 Apr;15(2):168-175. [PubMed: 27407060]
- 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]
- 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]
- 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]
- 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]
- 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]
- Jones BW. Evidence-based practice in hospice: is qualitative more appropriate than quantitative? Home Healthc Nurse. 2013 Apr;31(4):184-8. [PubMed: 23549249]
- 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]
- 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]
- 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.
