When documenting hospice eligibility for a cardiopulmonary diagnosis you MUST go beyond the disease-specific LCD guidelines to avoid denial under medical review.  Many people who suffer from advanced cardiopulmonary disease share multiple symptoms as the disease progresses, however, the symptoms affect each patient differently and therefore, must be documented this way in order to support each patient’s terminal condition. The diseases that affect the cardiopulmonary system often result in frequent exacerbations at different levels of severity. In addition, there is most likely a list of contributing factors and related conditions that further complicate the condition. Due to the variety of symptoms that characterize the patient with a cardiopulmonary condition, you must include the patient-specific findings of all contributing diagnosis when documenting towards a prognosis of six months or less.

Hospice referrals are typically made for the patient with advanced cardiopulmonary illness following a severe exacerbation or multiple exacerbations requiring increased visits to the physician or emergency room and/or multiple hospitalizations. Therefore, many of the patients admitted to hospice with this type of advanced disease clearly meet the disease-specific Local Coverage Determination (LCD) guidelines and the general decline LCD guidelines. The problem is, the patient’s terminal condition is not supported in documentation throughout hospice care as we continue to see the number one reason for claim denial under Targeted Probe and Educate (TPE) is documentation not supporting the terminal prognosis.

The LCD guidelines should be used as a guide however, checkboxes alone are not enough, the documentation must provide the details. Below are some of the common checkboxes found within the LCD guidelines for cardiopulmonary diseases that require additional documentation from the patient assessment findings in order to support a six month or less prognosis.

Shortness of breath

  • When does this occur: At rest? With exertion (how much exertion)? When eating? During conversation? These symptoms of debilitating dyspnea are expected to be present with continuous supplemental oxygen.
  • Does the patient experience paroxysmal nocturnal dyspnea (waking up at night short of breath)?
  • What does the patient experience with the shortness of breath: Cyanosis of the lips or nails beds? Use of accessory muscles for breathing? Chest pain? Orthopnea? What is the recovery time to get back to the patient’s baseline?
  • How does this impact the patient daily? (Not just during your visit)
  • Symptoms that occur while the patient is at rest strongly support the terminal condition.

Edema/swelling

  • Does the patient have significant edema despite optimal treatment?
  • Where is the edema: from the knee down bilaterally or just in the bilateral ankles? What interventions have been tried in the past and failed? If weight loss supported eligibility at the hospice SOC and now the patient has a weight gain is it due to the increased edema? Make sure you document this to support the reason for the weight gain.
  • How is the edema described: pitting edema 1, 2, 3+, etc., weeping, patient unable to wear shoes due to the swelling, is the edema painful?
  • Is there evidence of periorbital edema?
  • What effect does this have on a daily basis?

Lung sounds

  • How does the lung sounds differ from healthy breathing?
  • Be descriptive is there wheezes, crackles, rhonchi present and where specifically? Diminished lung sounds are expected, what else is present during the lung assessment?
  • What is the depth of respiration during the assessment? Does the patient become symptomatic when asked to take a series of deep breaths? Does coughing occur?

Oral intake

  • What is the percentage of meal consumption daily? Has this changed since the last visit?
  • If there is a decline in oral intake be descriptive: how is this different from the patient’s baseline? How has it changed over time? Does the patient have difficulty staying awake during meals? What are the portion sizes and percent of portions consumed? “The patient only consumed 2 bites of his/her cup of oatmeal for breakfast and breakfast is usually her best meal consuming 75% on average” is more descriptive than a general comment of “poor intake or intake declining”. Make sure to include s/s of weight loss such as loose-fitting clothes, decrease in mid-arm circumference measurement or weight changes when there is a decrease in consumption percentages.
  • Inadequate oral intake documented by decreasing food portion consumption along with weight loss are indicators of disease progression. Be sure to obtain both mid-arm circumference measurement and weight at the time of admission for a baseline.

Other common indicators

  • Infection within the last six months requiring antibiotic treatment.
  • Weight loss/weight gain – If weight loss is used to support ongoing hospice eligibility make sure you are able to explain weight gain if it occurs for example, “The patient has an increase in edema (provide the specific measurements) resulting in a weight gain of 2 pounds with no change in left mid-arm circumference measurement, fine crackles throughout the bilateral lower lobes, increased shortness of breath at rest requiring an increase in the diuretic dose for three days.” This example shows both disease progression and explanation of the weight gain.
  • Syncope episodes/falls with or without injury
  • Cognitive decline
  • Increase sleeping/napping throughout the day and/or after meals may indicate disease progression if the documentation supports the changes over time.
  • All related conditions that impact the terminal condition.

When reading a hospice nurse’s visit note you should be able to identify the following:

1. The patient’s hospice primary terminal diagnosis
2. The patient’s terminal condition supporting six months or less prognosis
3. Confirmation that hospice care is still needed
4. Persistent and/or new symptoms of disease progression
5. How the life-limiting illness is impacting the patient/family day to day
6. Patient/family response to interventions and progress towards goals

In order to avoid claim denials when a cardiopulmonary diagnosis is a primary reason for hospice care, you must be able to show the patient’s terminal condition in every visit note. This includes all nursing visit documentation as well as, documentation from other members of the IDG including the social worker, chaplain, and volunteer who bring additional insight to the patient’s condition.

Stay educated and informed by joining leading Hospice educator, Leslie Heagy, Clinical Services Manager during any of our 6 annual Hospice webinars.

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