Introduction
Hospice care is a specialized type of healthcare that adopts a holistic approach, focusing on enhancing the quality of life for individuals facing a terminal illness. This service is delivered by an interdisciplinary team, often under the direction of a physician who is board-certified in hospice and palliative medicine. These physicians possess specialized training beyond their initial residency, often through dedicated fellowships, making them experts in managing end-of-life care.
Many patients present with multiple health conditions, any of which could potentially qualify them for hospice. The core principle of hospice is to provide palliative care and manage complex symptoms for patients with a life expectancy of six months or less. Determining hospice eligibility requires a comprehensive evaluation, considering various factors such as the patient’s diagnoses, their impact on prognosis, and appropriate treatment plans. It’s crucial to distinguish between chronic conditions that are stable and those that significantly affect a patient’s terminal prognosis. Some treatments for chronic conditions might become burdensome or futile in the terminal stages of life, making palliative approaches more appropriate. Therefore, a holistic assessment of all conditions is necessary to accurately determine hospice eligibility and tailor care plans.
Research consistently demonstrates that hospice care improves the quality of life for patients nearing the end of life. However, studies also reveal that hospice patients, on average, live only about 2.5 months after enrollment, despite an initial prognosis of six months or less by their primary physician. This statistic highlights a critical issue: patients are frequently referred to hospice services much later than when they actually become eligible. Hospice is intended for individuals with a prognosis of six months or less, yet many patients only access these services in the final 2.5 months of life. The reasons for this delayed access warrant further investigation. It’s evident that patients are missing out on the comprehensive benefits of hospice care by not being enrolled sooner after meeting eligibility criteria. Early referral ensures that patients and their families can fully utilize the physical, emotional, and spiritual support offered by hospice services for a more extended period.
Initiating hospice service is more complex than simply receiving a prognosis of fewer than six months to live from a primary physician. A detailed and meticulous assessment is required for a successful transition into hospice care. The evolving landscape of healthcare guidelines, revised standards, and updated ICD codes continually shapes the interpretation and application of hospice diagnoses and regulations. Furthermore, the Centers for Medicare and Medicaid Services (CMS) regularly updates its expectations regarding billing and coding for hospice services, adding another layer of complexity.
Navigating the assessment of appropriate hospice diagnoses can be challenging for healthcare providers who are not specialized in this area. Hospice physicians and organizations play a vital role in providing clarity and guidance. These entities can assist in determining patient eligibility for hospice, especially for those with complex or less common terminal illnesses. Hospice organizations also offer invaluable support by facilitating sensitive conversations with patients and families, explaining the benefits of hospice care and addressing their concerns. Given the intricate nature of the approval process, early referral to hospice services after a terminal diagnosis is strongly encouraged. This proactive approach ensures a smoother integration into longitudinal care and allows patients to benefit from hospice support for as long as they are eligible. Ultimately, hospice agencies bear the responsibility for ensuring that all patients under their care meet the eligibility criteria for hospice and that the services provided are medically necessary and aligned with patient needs.
CMS’s approach to hospice-appropriate diagnoses has undergone significant evolution. A notable shift is the move from focusing solely on a primary hospice diagnosis to considering all relevant conditions, whether directly related to the terminal condition or not, that impact a patient’s prognosis. The Uniform Hospital Discharge Data Set defines the principal diagnosis as “the condition after study chiefly responsible for causing admission of the patient to the hospital.” In the context of hospice, the principal diagnosis is the condition considered most significant in 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 need for specific sequencing.
Diagnoses are not static; they are dynamic and may change as a patient’s condition progresses through the terminal stages. Regularly updating and documenting diagnoses, including additions and deletions, is crucial. Maintaining static diagnoses over time might inaccurately suggest stability in a patient’s condition, potentially prompting an unwarranted reevaluation of their hospice eligibility. Continuous monitoring and adjustment of diagnoses reflect the evolving nature of terminal illnesses and ensure that the hospice plan of care remains appropriate and responsive to the patient’s changing needs.
Determining a patient’s terminal prognosis, specifically a life expectancy of six months or less, often involves considering multiple hospice-appropriate diagnoses. It is imperative that all diagnoses are confirmed by a physician or authorized provider who assumes legal responsibility for establishing the patient’s diagnoses. This physician certification is a critical component of the hospice admission process, ensuring medical necessity and appropriate utilization of hospice services. 1, 2, 3, 4
Key Concerns in Hospice Diagnosis
Common concerns surrounding hospice-appropriate diagnoses primarily relate to obtaining and maintaining service approvals, alongside navigating the complexities of billing and coding. Frequently encountered challenges include the accurate application of symptom codes, the use of combination codes to represent complex conditions, and effectively coding diagnoses that may not be explicitly listed in standard coding manuals. Emerging areas of concern involve specific diagnoses that present ambiguities, such as accurately diagnosing and documenting dementia progression for hospice eligibility. Other complexities arise when determining if a fracture can serve as a primary hospice diagnosis, correctly sequencing primary versus secondary neoplasms in coding, and differentiating between acute and late-effect codes for cerebrovascular diagnoses. 5, 6
Clinical Significance of Accurate Hospice Diagnosis
Each patient’s journey through a terminal illness is unique, and their hospice care must reflect this individuality. Numerous diagnoses and underlying conditions can significantly influence the care required during the final stages of life. Comprehensive, clear, and factual documentation is paramount, accurately portraying the patient’s overall condition and the specific impact of their diagnoses on their prognosis. Regular re-evaluation of the patient’s status is essential to confirm ongoing hospice appropriateness. This re-evaluation should consider the patient’s physical, mental, social, and spiritual needs holistically. CMS guidelines emphasize the importance of coding all active, current diagnoses in the patient’s documentation. Conversely, historical diagnoses that no longer affect the patient’s current status or prognosis (“history codes”) should be removed, adhering to established coding guidelines. Hospice claims can accommodate up to twenty-five diagnoses. In situations where certain diagnoses lack specific codes or cannot be included in the diagnosis section, these conditions can still be addressed and covered within the narrative section of the patient’s plan of care documentation. The process of enrolling patients in hospice and determining hospice-appropriate diagnoses demands critical thinking from the physician. This includes maintaining an up-to-date list of all relevant conditions and removing any historical codes that are no longer pertinent to the patient’s current health status.
For practical guidance, the Centers for Medicare and Medicaid Services provides assessment criteria for disease progression and non-disease-specific baseline guidelines to aid in determining hospice eligibility. An abridged version of these criteria is outlined below:
Part 1: Guidelines for Decline in Clinical Status
A. Progression of disease is indicated by worsening status, symptoms, signs, and laboratory results:
-
Clinical Status:
- Refractory or recurring infections
- Progressive inanition documented by measures such as:
- 10% body weight loss
- Decreased albumin levels
- Dysphagia leading to aspiration
- And other relevant indicators
-
Symptoms:
- Nausea and vomiting
- Dyspnea
- Persistent cough
- Fatigue
- Decreased cognition
- Diarrhea
- Progressive pain
- And other significant symptoms
-
Signs:
- Hypotension
- Edema
- Ascites
- Progressive weakness
- New or altered mental status
- And other concerning clinical signs
-
Laboratory Results:
- Worsening pCO2/pO2/SaO2 values
- Worsening liver function tests
- Worsening tumor markers
- Volatile sodium and potassium levels
- And other deteriorating lab findings
B. Progressive disease leading to a decline in Karnofsky Performance Status or Palliative Performance Score. 7
C. Worsened functional assessment staging of diagnosed dementia.
D. Increased need for assistance with Activities of Daily Living (ADLs).
E. Worsening refractory stage 3 to stage 4 pressure ulcers despite optimal wound care.
F. Increased healthcare utilization such as emergency room visits, hospital admissions, and physician appointments related to the primary hospice diagnosis prior to seeking hospice benefits.
Part 2: Non-Disease Specific Baseline Guidelines (Both A and B criteria must be met)
A. Physiological impairment of functional status as indicated by a Karnofsky Performance Status or Palliative Performance Score of less than 70 percent.
B. Requirement of assistance for two or more ADLs:
- Ambulation
- Transferring
- Dressing
- Feeding
- Continence
- Bathing
C. Comorbidities: When a condition is not the primary hospice diagnosis, the presence of significant comorbid diseases that contribute to a prognosis of 6 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 (cancer)
- Acquired immunodeficiency syndrome/HIV
- Dementia
- Refractory severe autoimmune diseases (e.g., lupus or rheumatoid arthritis)
- Recurrent sepsis
Conclusion
Accurate Hospice Care Diagnosis is fundamental to ensuring that patients receive timely and appropriate end-of-life care. A comprehensive understanding of hospice eligibility criteria, evolving CMS guidelines, and the nuances of coding various diagnoses is crucial for healthcare providers. By focusing on a holistic patient assessment, considering all relevant conditions, and engaging in proactive hospice referrals, we can improve the quality of life for individuals facing terminal illness and their families, allowing them to fully benefit from the compassionate and comprehensive support hospice care offers.
References
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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
Disclosures:
Dac Teoli and Abhishek Bhardwaj declare no relevant financial relationships with ineligible companies.
