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Hospice
Qualification
Medicare
guidelines
Hospice
Qualification
guidelines
Coverage Indications, Limitations, and Medical Necessity
Coverage for hospice depends on a physician’s certification that an individual’s prognosis includes a life expectancy of six months or less if the terminal illness follows its normal course.
Navigating decisions regarding life limiting conditions requires sensitivity and understanding, and we’re here to offer compassionate guidance. Here are the broad Medicare guidelines for hospice eligibility:
- A doctor certifies the patient has a terminal illness.
- Life expectancy is six months or less if the illness follows its typical path.
- This prognosis is confirmed by both the attending physician (if any) and the hospice medical director.
- The focus of care shifts from curative treatment to comfort and symptom management.
- The patient agrees to receive hospice care.
- ALZheimer's - Eligibility GUidelines
- A physician must certify that the patient has a terminal illness with a life expectancy of six months or less if the dementia follows its typical course.
- The patient should demonstrate significant functional limitations, typically indicated by Stage 7 or beyond on the Functional Assessment Staging Scale (FAST). This often includes:
- Inability to ambulate without assistance.
- Inability to dress without assistance.
- Inability to bathe without assistance.
- Urinary and fecal incontinence (intermittent or constant).
- The patient should also have experienced one or more of the following conditions within the past 12 months:
- Aspiration pneumonia.
- Pyelonephritis or other upper urinary tract infection.
- Septicemia (severe bloodstream infection).
- Multiple stage 3 or 4 pressure ulcers (bedsores).
- Recurrent fever after antibiotic treatment.
- Inability to maintain sufficient fluid and calorie intake, evidenced by significant weight loss.
- The focus of care must shift from disease-modifying treatment to comfort care and symptom management.
It’s important to note that these are general guidelines, and the specific clinical judgment of the physician, considering the individual patient’s overall condition and rate of decline, is crucial in determining hospice eligibility
- Cancer - Eligibility Guidelines
- A physician must certify that the patient has a terminal illness, specifically advanced cancer, with a life expectancy of six months or less if the disease follows its typical course. This assessment considers the stage of the cancer, its responsiveness to treatment, and the presence of metastases or other complications.
- The cancer must be at a point where curative treatments are no longer effective, are no longer being pursued by the patient, or are causing more burden than benefit. The focus of care shifts towards comfort and symptom management rather than attempting to cure the disease.
- The patient should be experiencing significant symptoms related to their cancer, such as pain, fatigue, nausea, vomiting, shortness of breath, or weight loss, that require palliative management.
- There is no requirement to be bedridden to qualify for hospice with cancer. The key factor is the physician’s clinical judgment regarding the terminal nature of the illness and the limited life expectancy.
- The patient (or their legal representative) must consent to hospice care, understanding that the focus will be on comfort and quality of life rather than aggressive anti-cancer treatments.
- Documentation should clearly outline the advanced stage of the cancer, the lack of response to treatment or decision to forgo further curative treatment, and the presence of significant symptoms.
It’s crucial to understand that these are general guidelines. The specific clinical picture of each cancer patient will be unique, and the physician’s expert judgment is paramount in determining hospice eligibility based on the individual’s overall condition and prognosis.
- Lung Disease - Eligibility Guidelines
- A physician must certify that the patient has a terminal lung disease with a life expectancy of six months or less if the illness follows its typical course. This assessment considers the severity of the lung disease, its progression, and the patient’s response to treatment.
- The patient should exhibit significant symptoms related to their lung disease, such as:
- Disabling dyspnea (shortness of breath) at rest or with minimal exertion, often poorly responsive to bronchodilators.
- Frequent exacerbations leading to increased emergency room visits or hospitalizations for respiratory infections or respiratory failure.
- Progressive decline in functional status, often described as a “bed to chair” existence.
- Chronic, persistent cough.
- Fatigue that significantly limits daily activities.
- Objective clinical findings that support hospice eligibility for lung disease include:
- Hypoxemia at rest on room air, evidenced by:
- Partial pressure of oxygen (PaO2) less than or equal to 55 mmHg.
- Oxygen saturation (O2 sat) less than or equal to 88%.
- Hypercapnia, evidenced by a partial pressure of carbon dioxide (PaCO2) greater than or equal to 50 mmHg. (This value may be from recent hospital records, typically within the last 3 months).
- Forced Expiratory Volume in one second (FEV1) after bronchodilator less than 30% of predicted (if available). A serial decrease in FEV1 of greater than 40 ml per year can also indicate disease progression.
- Hypoxemia at rest on room air, evidenced by:
- Other supporting factors that may be considered include:
- Right heart failure (Cor pulmonale) secondary to the lung disease (not due to left heart disease or valvular issues).
- Unintentional progressive weight loss of greater than 10% of body weight over the preceding six months.
- Resting tachycardia (heart rate greater than 100 beats per minute)
start your
CARE JOURNEY
Are you looking for hospice care for your loved one? Do you feel overwhelmed and unsure of whereA to begin? Our knowledgeable and professional staff will answer any questions that you may have and help guide you on the next steps.
start your
CARE JOURNEY
Are you looking for hospice care for your loved one?
Do youfeel overwhelmed and unsure of where to begin?
Our knowledgeable and professional staff will answer any questions that you may have and help guide you on the next steps.