Some diseases have a fairly standard progression. For instance, patients with more advanced Alzheimer’s disease may experience changes in their ability to ambulate, to speak, or to swallow. Other illnesses, however, have less well-documented stages. Additionally, sometimes a patient’s diagnosis is not clear-cut.
The Centers for Medicare and Medicaid Services (CMS) has established Local Coverage Determination guidelines that help medical professionals gauge the appropriateness of hospice for a patient. These include:
- Progression of disease
- Decline in Karnofsky Performance Status (KPS) or Palliative Performance Score (PPS) from <70% due to progression of disease.
- Increasing emergency room visits, hospitalizations, or physician’s visits related to hospice primary diagnosis
- Progressive decline in Functional Assessment Staging (FAST) for dementia (from ≥7A on the FAST)
- Progression to dependence on assistance with additional activities of daily living (See Part II, Section 2)
- Progressive stage 3-4 pressure ulcers in spite of optimal care
It is important to note that CMS recognizes that, even given the LCD guidelines, an accurate prediction is, in most cases, not possible. Thus, the physician’s assessment and recommendation to hospice should be made based on a patient’s specific circumstances.
According to the National Center for Biotechnology Information (CBI):Fear of being accused of Medicare fraud by attesting incorrectly to a limited prognosis probably keeps many honest and caring physicians from appropriate, timely referral for the hospice benefits to which patients are entitled. However, the Medicare Claims Processing Manual, Chapter 11 (revised in April 2010) advises fiscal intermediaries, “It should be noted that predicting life expectancy is not always exact.” Incorrect prognoses made in good faith do not serve as the basis for fraud investigations.
If you are considering whether to refer a patient for hospice care, a Shining Light Hospice caregiver would be happy to conduct an evaluation of whether hospice is recommended given the patient’s status.