Comprehensive Hospice Diagnosis List: Eligibility Guidelines for End-of-Life Care

General Guidelines:

To certify a patient for hospice care, documentation must clearly demonstrate terminal status. This requires sufficient information to support the determination of a life expectancy of six months or less if the illness runs its normal course. Documentation aligning with the “Indications” section of this policy fulfills this requirement. Should clinical indicators outside this policy, such as psychological or spiritual factors, serve as the basis for terminal status certification, these must also be documented. Recertification for hospice care demands the same clinical standards as initial certification, though reiteration is unnecessary. Reference to prior documentation is acceptable for recertification. However, it is crucial to note paragraph 3 of ‘General Indications’ under “Indications and Limitations of Coverage and/or Medical Necessity” concerning patients who show improvement or stabilization.

Documentation should create a vivid picture for reviewers, illustrating the patient’s suitability for hospice and the necessary level of care (routine home, continuous home, inpatient respite, or general inpatient). Records should emphasize observations and data rather than mere conclusions. Documentation expectations should align with standard clinical documentation practices. Unless record elements require clarification, such as a non-morbid diagnosis or indicators suggesting survival beyond six months, no additional record entries are needed to establish hospice benefit eligibility.

The extent and detail of documentation will vary depending on the situation. For instance, a patient with metastatic small cell carcinoma may require less documentation to demonstrate hospice eligibility compared to a patient with chronic lung disease. These cases are typically self-evident. Patients with chronic lung disease, those with extended hospice stays, or those appearing stable can still qualify for hospice benefits, but the record must provide adequate justification for a prognosis of less than six months.

Any documentation findings that contradict or cast doubt on a prognosis of less than six months must be addressed and explained or refuted by other entries. Most factors suggesting a prognosis exceeding six months are generally predictable, such as prolonged hospice stays or diagnoses not immediately life-threatening. Specific entries, such as a team member’s opinion or improvement in ADLs previously used to establish eligibility, may also require clarification. Furthermore, the absence of certain documentation, like a tissue diagnosis for cancer, does not automatically disqualify hospice eligibility but necessitates additional supporting documentation.

Submitted documentation can include information from periods preceding the current billing period. Relevant supporting events include changes in activities of daily living, recent hospitalizations, and the date of death, especially when billing for periods before death occurred.

Documentation must justify the level of care provided during the review period, whether routine, continuous home, inpatient, respite, or general. Reviewers should easily discern dates and times of care level changes and their reasons.

Furthermore, all documentation must adhere to the requirements outlined in CMS IOM 100-02 Chapter 9 Section 20.

Disease Specific Guidelines

Note: These guidelines are to be used alongside the “Non-disease specific baseline guidelines” detailed in Part II of the basic policy.

Section I: Cancer Diagnoses

A. Cancer diagnosed with distant metastases at initial presentation OR
B. Progression from an earlier cancer stage to metastatic disease, accompanied by either:

1. Continued decline despite ongoing therapy
2. Patient’s decision to forgo further disease-directed treatment

Note: Certain cancers known for poor prognoses, such as small cell lung cancer, brain cancer, and pancreatic cancer, may qualify for hospice even without meeting the criteria above.

Section II: Non-Cancer Diagnoses

A. Amyotrophic Lateral Sclerosis (ALS)

General Considerations:

1. ALS typically progresses linearly over time, with each patient exhibiting a relatively consistent and predictable rate of decline, unlike many other non-cancerous diseases.
2. No single symptom deteriorates uniformly across all ALS patients. Therefore, assessing ALS progression requires evaluating multiple clinical indicators.
3. Although ALS often begins in a localized area, the initial presentation site does not correlate with survival time. By the end-stage, muscle denervation is widespread, affecting all body areas, and initial symptom patterns become less distinct.
4. Disease progression varies significantly among patients. Some experience rapid decline and quick mortality, while others progress more slowly. Consequently, understanding an individual patient’s progression rate history is crucial for prognosis prediction.
5. In end-stage ALS, respiratory function and, to a lesser extent, swallowing ability are critical prognostic factors. Respiratory issues can be managed with artificial ventilation, and swallowing difficulties with gastrostomy or artificial feeding, unless recurrent aspiration pneumonia occurs. While not necessarily contraindicating hospice care, artificial ventilation or feeding significantly alters a six-month prognosis.
6. Neurological examination within three months of hospice assessment is recommended to confirm diagnosis and aid prognosis.

Criteria: Patients are considered in the terminal stage of ALS (life expectancy of six months or less) if they meet one of the following criteria (1, 2, or 3):

1. Critically Impaired Breathing Capacity: Evidenced by ALL of the following within the 12 months before initial hospice certification:
   a. Vital capacity (VC) less than 30% of normal (if measured);
   b. Dyspnea at rest;
   c. Patient declines mechanical ventilation, accepting external ventilation only for comfort.
2. Rapid ALS Progression AND Critical Nutritional Impairment:
   a. Rapid Progression of ALS: Demonstrated by ALL of the following within 12 months before initial hospice certification:
   i. Progression from independent walking to wheelchair use to bedridden status.
   ii. Speech decline from normal to barely intelligible or unintelligible.
   iii. Diet progression from normal to pureed consistency.
   iv. Decline from independence in most or all ADLs to requiring major caregiver assistance in all ADLs.
   b. Critical Nutritional Impairment: Demonstrated by ALL of the following within 12 months before initial hospice certification:
   i. Insufficient oral intake of nutrients and fluids to sustain life.
   ii. Ongoing weight loss.
   iii. Dehydration or hypovolemia.
   iv. Absence of artificial feeding methods intended to sustain life, but not for hunger relief.
3. Rapid ALS Progression AND Life-Threatening Complications:
   a. Rapid Progression of ALS: (See criteria 2.a above).
   b. Life-Threatening Complications: Demonstrated by ONE of the following within 12 months before initial hospice certification:
   i. Recurrent aspiration pneumonia (with or without feeding tubes).
   ii. Upper urinary tract infection, such as pyelonephritis.
   iii. Sepsis.
   iv. Recurrent fever despite antibiotic therapy.
   v. Stage 3 or 4 pressure ulcers.

B. Dementia due to Alzheimer’s Disease and Related Disorders

Patients with dementia are considered in the terminal stage (life expectancy of six months or less) if they exhibit ALL of the following:

1. Stage seven or beyond on the Functional Assessment Staging Scale (FAST).
2. Inability to ambulate without assistance.
3. Inability to dress without assistance.
4. Inability to bathe without assistance.
5. Urinary and fecal incontinence, intermittent or constant.
6. No consistent meaningful verbal communication; using only stereotypical phrases or speaking limited to six or fewer intelligible words.

AND have experienced ONE of the following within the past 12 months:

1. Aspiration pneumonia.
2. Pyelonephritis or other upper urinary tract infection.
3. Septicemia.
4. Stage 3-4 pressure ulcers, multiple.
5. Recurrent fever after antibiotics.
6. Inability to maintain sufficient fluid and calorie intake with 10% weight loss over the preceding six months or serum albumin <2.5 gm/dl.

Note: This section specifically applies to Alzheimer’s Disease and related disorders, not other dementia types like multi-infarct dementia.

C. Heart Disease

Patients with heart disease are considered in the terminal stage (life expectancy of six months or less) if they meet the following criteria (criteria 1 and 2 are required; factors from 3 provide supporting documentation):

1. At hospice initial certification or recertification, the patient is currently or has been optimally treated for heart disease, is not a candidate for surgical procedures, or has declined such procedures. (Optimal treatment means patients not on vasodilators have a medical reason for refusal, such as hypotension or renal disease.)
2. The patient is classified as New York Heart Association (NYHA) Class IV and may experience significant heart failure symptoms or angina at rest. (Class IV heart disease patients cannot perform physical activity without discomfort. Heart failure or angina symptoms may be present even at rest, and discomfort increases with any physical activity.) An ejection fraction of ≤20% can document significant congestive heart failure but is not mandatory if unavailable.
3. Documentation of the following factors supports hospice eligibility but is not required:
   a. Treatment-resistant symptomatic supraventricular or ventricular arrhythmias.
   b. History of cardiac arrest or resuscitation.
   c. History of unexplained syncope.
   d. Brain embolism of cardiac origin.
   e. Coexisting HIV disease.

D. HIV Disease

Patients with HIV are considered in the terminal stage (life expectancy of six months or less) if they meet the following criteria (criteria 1 and 2 are required; factors from 3 provide supporting documentation):

1. CD4+ Count <25 cells/µL OR Viral Load >100,000 copies/ml, PLUS one of the following:
   a. CNS lymphoma.
   b. Untreated or treatment-resistant wasting (loss of ≥10% lean body mass).
   c. Mycobacterium avium complex (MAC) bacteremia, untreated, unresponsive, or treatment refused.
   d. Progressive multifocal leukoencephalopathy.
   e. Systemic lymphoma with advanced HIV and partial chemotherapy response.
   f. Visceral Kaposi’s sarcoma unresponsive to therapy.
   g. Renal failure without dialysis.
   h. Cryptosporidium infection.
   i. Toxoplasmosis, unresponsive to therapy.
2. Decreased performance status, measured by Karnofsky Performance Status (KPS) scale, ≤50%.
3. Documentation of the following factors supports hospice eligibility:
   a. Chronic persistent diarrhea for one year.
   b. Persistent serum albumin <2.5 gm/dl.
   c. Coexisting active substance abuse.
   d. Age >50 years.
   e. Absence of or resistance to effective antiretroviral, chemotherapeutic, and prophylactic drugs specifically for HIV.
   f. Advanced AIDS dementia complex.
   g. Toxoplasmosis.
   h. Symptomatic congestive heart failure at rest.
   i. Advanced liver disease.

E. Liver Disease

Patients with liver disease are considered in the terminal stage (life expectancy of six months or less) if they meet the following criteria (criteria 1 and 2 are required; factors from 3 provide supporting documentation):

1. The patient must exhibit both a and b:
   a. Prothrombin time prolonged by more than 5 seconds over control, or International Normalized Ratio (INR) >1.5.
   b. Serum albumin <2.5 gm/dl.
2. End-stage liver disease is present, with at least one of the following:
   a. Ascites, refractory to treatment or patient non-compliance.
   b. Spontaneous bacterial peritonitis.
   c. Hepatorenal syndrome (elevated creatinine and BUN with oliguria).
   d. Hepatic encephalopathy, refractory to treatment or patient non-compliance.
   e. Recurrent variceal bleeding despite intensive therapy.
3. Documentation of the following factors supports hospice eligibility:
   a. Progressive malnutrition.
   b. Muscle wasting with reduced strength and endurance.
   c. Continued active alcoholism (>80 gm ethanol/day).
   d. Hepatocellular carcinoma.
   e. HBsAg (Hepatitis B) positivity.
   f. Hepatitis C refractory to interferon treatment.

Patients awaiting liver transplants who meet these criteria may be certified for Medicare hospice benefits. However, hospice discharge is required if a donor organ becomes available.

F. Pulmonary Disease

Patients with pulmonary disease are considered in the terminal stage (life expectancy of six months or less) if they meet the following criteria. These criteria apply to advanced pulmonary disease patients progressing towards a common end-stage pathway (criteria 1 and 2 are required; documentation of 3, 4, and 5 provides supporting evidence):

1. Severe chronic lung disease documented by both a and b:
   a. Disabling dyspnea at rest, poorly responsive to bronchodilators, causing reduced functional capacity (e.g., bed-to-chair existence, fatigue, and cough). (FEV1 after bronchodilator <30% predicted objectively indicates disabling dyspnea but is not mandatory.)
   b. Progression of end-stage pulmonary disease, evidenced by increased emergency department visits, hospitalizations for pulmonary infections and/or respiratory failure, or increased physician home visits before initial certification. (Serial FEV1 decrease >40 ml/year objectively indicates disease progression but is not mandatory.)
2. Hypoxemia at rest on room air, evidenced by pO2 ≤55 mmHg or oxygen saturation ≤88%, from arterial blood gases or oxygen saturation monitors. (Values may be from recent hospital records.) OR Hypercapnia, evidenced by pCO2 ≥50 mmHg. (Value may be from recent [within 3 months] hospital records.)
3. Right heart failure (RHF) secondary to pulmonary disease (cor pulmonale), not due to left heart disease or valvulopathy.
4. Unintentional progressive weight loss of >10% body weight over the preceding six months.
5. Resting tachycardia >100/min.

G. Renal Disease

Patients with renal disease are considered in the terminal stage (life expectancy of six months or less) if they meet the following criteria.

Acute Renal Failure: (Criteria 1 and either 2 or 3 are required; factors from 4 provide supporting documentation.)

1. Patient is not seeking dialysis or renal transplant, or is discontinuing dialysis.
2. Creatinine clearance <10 ml/min (≤15 ml/min for diabetics).
3. Serum creatinine >8.0 mg/dl (>6.0 mg/dl for diabetics).
4. Comorbid conditions:
   a. Mechanical ventilation.
   b. Malignancy (other organ system).
   c. Chronic lung disease.
   d. Advanced cardiac disease.
   e. Advanced liver disease.
   f. Sepsis.
   g. Immunosuppression/AIDS.
   h. Albumin <2.5 gm/dl.
   i. Cachexia.
   j. Platelet count <25,000.
   k. Disseminated intravascular coagulation.
   l. Gastrointestinal bleeding.

Chronic Renal Failure:

(Criteria 1 and either 2 or 3 are required; factors from 4 provide supporting documentation.)

1. Patient is not seeking dialysis or renal transplant, or is discontinuing dialysis.
2. Creatinine clearance <10 ml/min (≤15 ml/min for diabetics).
3. Serum creatinine >8.0 mg/dl (>6.0 mg/dl for diabetics).
4. Signs and symptoms of renal failure:
   a. Uremia.
   b. Oliguria <400 ml/24 hours.
   c. Intractable hyperkalemia (>7.0) unresponsive to treatment.
   d. Uremic pericarditis.
   e. Hepatorenal syndrome.
   f. Intractable fluid overload, unresponsive to treatment.

H. Stroke & Coma

Patients with stroke or coma are considered in the terminal stage (life expectancy of six months or less) if they meet the following criteria.

Stroke:

1. Karnofsky Performance Status (KPS) or Palliative Performance Scale (PPS) ≤40%.
2. Inability to maintain hydration and caloric intake, with one of the following:
   a. Weight loss >10% in the last 6 months or >7.5% in the last 3 months.
   b. Serum albumin <2.5 gm/dl.
   c. Current history of pulmonary aspiration unresponsive to speech language pathology intervention.
   d. Sequential calorie counts documenting inadequate caloric/fluid intake.
   e. Dysphagia severe enough to prevent sufficient food and fluid intake to sustain life, in a patient who declines or does not receive artificial nutrition and hydration.

Diagnostic imaging factors supporting poor prognosis after stroke include:

For non-traumatic hemorrhagic stroke:

1. Large-volume hemorrhage on CT:
   a. Infratentorial: ≥20 ml.
   b. Supratentorial: ≥50 ml.
2. Ventricular extension of hemorrhage.
3. Hemorrhage surface area ≥30% of cerebrum.
4. Midline shift ≥1.5 cm.
5. Obstructive hydrocephalus in a patient declining or not eligible for ventriculoperitoneal shunt.

For thrombotic/embolic stroke:

1. Large anterior infarcts with cortical and subcortical involvement.
2. Large bihemispheric infarcts.
3. Basilar artery occlusion.
4. Bilateral vertebral artery occlusion.

Coma (any etiology): Comatose patients with any 3 of the following on day three of coma:

1. Abnormal brain stem response.
2. Absent verbal response.
3. Absent withdrawal response to pain.
4. Serum creatinine >1.5 mg/dl.

Documentation of the following factors supports hospice eligibility:

Documentation of medical complications within the previous 12 months, in the context of progressive clinical decline, supporting a terminal prognosis:

1. Aspiration pneumonia.
2. Upper urinary tract infection (pyelonephritis).
3. Sepsis.
4. Refractory stage 3-4 pressure ulcers.
5. Recurrent fever after antibiotics.