The Medicare Administrative Contractors (MACs) Cigna Government Services (CGS), National Government Services (NGS), and Palmetto, have set disease-specific criteria for pulmonary disease eligibility that include assessing the non-disease specific criteria alongside the disease-specific criteria. As with all diagnoses for hospice patients, eligibility is ultimately determined by the physician’s narrative statement in the Certification of Terminal Illness (CTI). A life expectancy of six months or less if the disease runs its expected course is required for eligibility, along with the following LCD criteria.
Examining LCD Criteria
The MACs group all end-stage pulmonary conditions together (and Palmetto includes all cardiac diseases in the same LCD as pulmonary). NGS and CGS state that despite different reasons for these conditions starting, at the end stages of the diseases, the presentation is much the same. Due to the long progression of pulmonary disease, it can be challenging to determine when a patient has entered the terminal stage of the diseases. Reviewing the LCDs for this disease group can assist help agencies with documenting appropriately in the hospice software to reduce the risk of failing an Additional Development Request (ADR).
NGS and CGS have specific criteria in the LCD for pulmonary conditions, stating that disabling dyspnea at rest that is poorly or unresponsive to bronchodilators should be present, resulting in the patient having a decreased functional capacity as evidenced by fatigue, cough, and limited mobility due to shortness of breath. Also, NGS and CGS state that progression of end-stage disease should be evidenced by increased emergency room visits or hospitalizations for respiratory infections or respiratory failure, or increased home physician visits prior to the initial certification.
While objective data such as Forced Expiratory Volume in One Second (FEV1) deterioration is helpful and may be present in the clinical records of the primary care physician, hospital, or pulmonologist, they are not necessary to have present if they are not available. The presence of hypoxia at rest on room air as evidenced by either a partial pressure of oxygen (pO2) result of equal to or less than 55 mmHg or oxygen saturation result of less than or equal to 88% or hypercapnia, as evidenced by a partial pressure of carbon dioxide (pCO2) of equal to or greater than 50 mmHg should be present. Additional supporting documentation that is not required but recommended to document in your hospice software if present, include right heart failure secondary to pulmonary disease (cor pulmonale), unintentional progressive weight loss of greater than 10% of the body-weight over the prior six months, and resting tachycardia of greater than 100/min.
Palmetto takes a less specific and more structural and functional view of determining end-stage pulmonary diseases. They also state that identifying and documenting environmental factors and activity limitations in a hospice software along with how comorbidities and secondary conditions are impacting prognosis will bolster the eligibility claim for agencies. Secondary conditions are directly caused by the terminal diagnosis, while comorbidities are separate conditions that may impact prognosis but are not directly caused by the terminal disease. An example of a secondary condition in a patient with pulmonary disease would be delirium, pneumonia, and skin breakdown caused by poor oxygen perfusion to the skin. Comorbidity for a patient with pulmonary disease would include end-stage renal disease (ESRD) or diabetes mellitus (DM).
All MACs expect the hospice to determine the diagnoses that are related to the patient’s terminal prognosis and address them in the CTI narrative to accurately illustrate reasons the physician believes the patient has a prognosis of six months or less. Accurately identifying and assessing the patient’s full diagnoses will assist agencies with developing a proactive Plan of Care for addressing the patient’s needs during hospice care.
Determining the terminal stage of pulmonary disease is often based on the severity of dyspnea at rest that includes severe functional limitations despite optimal treatment, as well as increased use of physicians and hospitals due to respiratory failure and infections. While an exact prognosis is difficult to determine for patients with pulmonary disease, carefully documenting functional and activity limitations with hypoxia in hospice software will help agencies reduce worries about regulatory scrutiny.
