Definition/Introduction

Hospice is a medical service based on a holistic approach to providing quality end-of-life care to patients. Typically, there is an interprofessional team focus led by a physician medical director. Often, these physicians who manage and monitor care during the length of service have additional training beyond residency by completing a dedicated fellowship, thereby earning board certification in the medical subspecialty of hospice and palliative medicine.

In essence, most patients have multiple conditions, which could potentially be hospice-appropriate diagnoses. The basic foundation of hospice is offering palliative and complex symptomatic management to those with a life expectancy of six months or less. There are several layers of thought which need to be addressed before establishing current status and maintaining status on hospice services. Some diagnoses are chronic and stable without a meaningful impact on terminal prognosis. Some treatments for chronic conditions may cause more harm than good during the terminal stages of life. Alternatively, therapies might fall into the non-palliative category or be futile given the stage of the disease. There must be a complete evaluation of the totality of their conditions for each patient, including hospice-appropriate diagnoses and treatment plans.

Research has shown that hospice does improve the quality of life in patients. However, hospice patients live only 2.5 months, on average, once being provided a six-month prognosis by their primary physician and enrolled. This statistic lends risk to the common misconception that hospice services hasten death; however, in reality, it points to the issue that patients are often brought onto hospice services later than they were eligible. In other words, hospice services are for patients with a prognosis of 6 months or less until their death, yet patients are not utilizing hospice services until only 2.5 months until death. Why this is the case will indeed require further research; however, what is known is that, by patients being eligible for months before the referral eventually is made, patients are missing out on the numerous benefits that a comprehensive hospice service can provide to its patient population.

Enrollment into hospice service is not as simple as a patient’s primary physician making a prognosis of fewer than six months to live. On the contrary, many details need to be considered and meticulously assessed, and documented for a patient to transition into hospice successfully. As with each new set of guidelines, revised standards, or updated ICD codes, there are further changes to the interpretation and guidance of hospice diagnoses and regulations. Similarly, there is a consistent rolling out of new Centers for Medicare and Medicaid Services (CMS) expectations regarding billing and coding.

While the assessment of appropriate hospice diagnoses can be confusing for healthcare providers that are not required to stay abreast of the literature constantly, hospice physicians and organizations can offer valuable services to help answer questions and provide guidance. Hospice organizations can assist in determining eligibility for patients suffering from terminal illnesses. These same organizations can often provide thoughtful guided conversations with patients and their families about the benefits their services offer. As the process of gaining approval can be complicated, it is generally smiled upon to refer eligible patients to hospice services soon after a terminal diagnosis is rendered to help integrate excellent longitudinal care. Overall, the hospice organizational agency is responsible for all patients in their care to ensure their satisfaction of eligibility criteria for hospice and that their services are medically necessary.

As noted earlier, CMS has consistently updated its approach to hospice-appropriate diagnoses. Most recently, CMS has migrated away from only a primary hospice diagnosis and instead toward inclusion of all relevant and non-related conditions that impact prognosis or the underlying terminal condition. Uniform Hospital Discharge Data Set defines the primary or principal diagnosis as the “condition after study chiefly responsible for causing admission of the patient to the hospital.” Another way of understanding it is that the principal diagnosis is the one seen as most contributing to the 6-month prognosis for the patient. If there happen to be two hospice-appropriate diagnoses that contribute to the patient’s poor prognosis equally, requirements are that both be documented as the principal diagnosis, with sequencing between the two inconsequential.

Diagnoses are understandably dynamic. Diagnoses might change and need to be documented, with additions and deletions, as a patient progresses through the terminal stages of their conditions. In fact, static diagnoses over time might falsely convey stability of a patient’s condition and theoretical reevaluation of the patient as being an appropriate hospice candidate.

In respect to determining a patient’s terminal prognosis, with a life expectancy of six months or less, often individuals have multiple hospice appropriate diagnoses, and all diagnoses must be confirmed by a physician or provider which bears legal accountability for establishing diagnoses for the patient.[1][2][3][4]

Issues of Concern

Most of the issues of concern regarding hospice-appropriate diagnoses revolve around gaining and maintaining approval and billing and coding concerns. Specifically, frequently noted areas of concern involve successful utilization of symptom codes, combination codes, and successfully coding diagnoses that are not obviously listed in the manuals. Other areas of more recent concern involve specific diagnoses such as ambiguities involving dementia, establishing a fracture as the primary diagnosis, appropriately sequencing primary versus secondary neoplasms, and accurately documenting cerebrovascular diagnoses, which are acute versus late effect codes.[5][6]

Clinical Significance

Each patient must be seen as a unique person. Many diagnoses and conditions can impact the care of patients during the last stages of life. Documentation should aim to be complete, clear, and factual regarding the patient’s circumstances and the impact their diagnoses have on their prognosis. There should be a frequent re-evaluation of the patient’s status as appropriate for continued hospice care through the lens of physical, mental, social, and spiritual needs. CMS requests coding of all current diagnoses in the documentation. Therefore, diagnoses made in the past that have no bearing on the patient’s current status or ongoing prognosis (history codes) should be removed per coding guidelines. Hospice claims can support up to twenty-five diagnoses, and if there are some diagnoses without designated codes or for whatever reason cannot be placed in the diagnoses section, those conditions can receive coverage in the narrative part of the plan of care in the documentation. Overall the process of enrolling patients into hospice and determining hospice-appropriate diagnoses requires critical thinking by the physician, with maintaining a current list of conditions and removing inappropriate history codes when applicable.

For reference, below is an abridged version of the currently outlined assessment criteria for the progression of diseases and non-disease baseline guidelines as obtained from the Centers of Medicare and Medicaid Services:

Part 1: Decline in a patient's clinical status guidelines

A. Progression of disease via worsening status, symptoms, signs, laboratory results:

Clinical Status

• Refractory or recurring infections
• Progressive inanition is documented by several measures such as 10% body weight loss, decreased albumin, and dysphagia leading to aspiration, among others.

Symptoms

• Include a number of symptoms, including nausea and vomiting, dyspnea, persisting cough, fatigue, decreased cognition, diarrhea, and progressive pain

Signs

• Include a number of clinical signs, including hypotension, edema, ascites, progressive weakness, new altered mental status, among others

Laboratory Results

• Include a number of laboratory findings, including worsening pCO2/pO2/SaO2 values, worsening liver function tests, worsening tumor markers, and volatile sodium and potassium, among others

B. Progressive disease leading to worsened Karnofsky Performance Status or Palliative Performance Score.[7]

C. Worsened functional assessment staging of diagnosed dementia.

D. Requiring assistance with additional ADLs

E. Worsening refractory stage 3 to stage 4 pressure ulcers despite wound care

F. Increasing healthcare utilization in the form of emergency visits, hospital admissions, and physician appointments related to the primary hospice diagnosis before seeking hospice benefit

Part 2. Non-disease specific baseline guidelines (both points A and B must be satisfied).

A. Physiologic impairment of functional status as interpreted via the Karnofsky Performance Status or Palliative Performance Score of less than 70 percent.

B. Individual needs assistance for greater than or equal to 2 ADL's: ambulation; transfer; dressing; feeding; continence; and bathing.

C. Comorbidities: when the condition is not the designated primary hospice diagnosis, the presence of significant disease thought to contribute to a prognosis of 6 months or less survival should be considered, such as[8][9][10][11]:

• Chronic obstructive pulmonary disease (COPD)
• Congestive heart failure (CHF)
• Ischemic heart disease
• Diabetes mellitus
• Neurologic disease (cerebrovascular accident, Parkinson disease, multiple sclerosis, amyotrophic lateral sclerosis)
• Renal failure
• Liver disease
• Neoplasia
• Acquired immune deficiency syndrome/HIV
• Dementia
• Refractory severe autoimmune disease (e.g., lupus or rheumatoid arthritis)
• Recurrent sepsis