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When admitting a patient to hospice with a primary terminal diagnosis of Alzheimer’s disease, your documentation should clearly show the nature and condition causing the hospice admission in addition to, the hospice disease-specific LCD guidelines.

According to the Medicare Hospice Conditions of Participation under the §418.54(c) Standard: Content of the comprehensive assessment within the State Operations Manual Appendix M. The hospice comprehensive assessment must take into consideration the nature and condition causing the hospice admission. This should be the question answered for all hospice admission. Why hospice now?

The disease-specific LCD guideline: Alzheimer’s disease and Related Conditions for hospice should be used when determining hospice eligibility. If the patient meets the LCD criteria of both 1 and 2 below then the criteria for a six month or less prognosis is met.

  • 1. Is the patient at or beyond stage 7 of the Functional Assessment Staging (FAST) scale?
    • 7A – Ability to speak is limited to approximately 6 intelligible words or fewer in an average day or in the course of an intensive interview
      7B – Speech ability is limited to the use of a single intelligible word in an average day or in the course of an intensive interview (the person may repeat the word over and over)
      7C – Ambulatory ability is lost (cannot walk without personal assistance)
      7D – Cannot sit up without assistance. (e.g., patient will fall over without support of a pillow/wedge)
      7E – Loss of ability to smile.
      7F – Loss of ability to hold head up independently

If the patient’s has progressed to a FAST scale of 7A or beyond ALL of the following characteristics should also be present:

  • Inability to ambulate independently (assistance is needed)
  • Unable to bathe/dress self without assistance
  • Incontinence of bowel and bladder
  • Unable to speak or communicate meaningfully
  • 2. Has the patient had one or more of the following medical complications related to dementia in the past year?
    • Aspiration Pneumonia
    • Upper Urinary Tract Infection
    • Septicemia
    • Decubitus Ulcer, stage 3-4
    • Recurrent fever after antibiotic treatment
    • Inability or unwillingness to take food/fluid
    • Unintentional weight loss greater than 10% in the last 6 months
    • Serum albumin less than 2.5 gm/dl

Keep in mind all patients do not fit into a diagnosis box. You must consider how the terminal diagnosis and related conditions contribute to each patient’s terminal condition, as the cliché says…“Paint the Picture”.

First, you must meet the eligibility requirements for the hospice terminal diagnosis which includes the co-morbidities that contribute to the terminal prognosis.

Second, your documentation must support the eligibility requirements by including the patient’s clinical objective findings. The documentation should clearly show the terminal condition every visit not just at the time for recert.

Whether determining eligibility for the initial or recertification AND when documenting within individual visit notes consider the questions below for the Alzheimer’s patient:

  • Has there been any exacerbations of symptoms in the last 6 months?
  • What are the persistent signs/symptoms of the patient’s terminal condition? Is there evidence of new symptoms to support the terminal prognosis? (e.g. new infection or wound, sleeping more, weight loss, progression of FAST scale)
  • How are the persistent and/or new symptoms of disease progression impacting the patient’s day to day life?
  • What changes have occurred during the last 6-12 months that support disease progression?

REMEMBER: When documenting weight loss, increase sleeping, decrease appetite etc.… the medical record must include the objective measurable data to support these findings for it to be used to support hospice eligibility (e.g. weight loss in lbs and percentage of weight loss, # of hours of sleep in a 24 hours period). Make sure to include the changes over time otherwise, it may “paint the picture” of a chronic condition instead of a terminal condition.

REMEMBER: The patient’s baseline should always be documented at the hospice start of care allowing you to show changes over time for disease progression to support ongoing hospice eligibility.

The link below is for the disease-specific Hospice Alzheimer’s Disease & Related Disorders LCD (L34567).

https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx