Medicare Diagnosis Changes

tewdles, RN · Jun 8, 2013

I simply cannot believe that they would dismiss dementia as a suitable primary dx code!

Simply because we have difficulty predicting life span does NOT mean that people do not suffer and die from dementias on a regular basis.

HOLY *** Batman!

DLS_PMHNP, MSN, RN, NP · Jun 8, 2013

I agree about the dismissing the dementia dx; it is a horrible disease, in which both pts and family suffer. It is more predictable in terms of disease progression, than either AFTT or debility.

Stella1688 · Jun 10, 2013

I agree Tewdles and Nurse_Diane! In a way I am not surprised about AFTT and debility since they have been talking about that for years (and I believe some agencies do overuse these dx and put people on hospice that aren't quite appropriate), but dementia?! It is often clearly a terminal dx, without any other secondaries/comorbids that are enough to qualify for hospice. I really hope this is not going to happen...for now I am really trying not to use AFTT and debility, but with dementia and I am just documenting to the extreme.

tewdles, RN · Jun 10, 2013

We used debility a good bit, but our debility patients had a very "reasonable" life span, in hospice terms. Our debility patients were often VERY fragile and did not survive long.

Dementia dx should be opened to allow earlier use of hospice, IMHO as it is a cheaper and more humane approach to this disease constellation which WILL END IN DEATH.

pfeliks · Jun 13, 2013

I work for a national hospice. This month we've been told we can no longer use AFTT or Debility as primary hospice diagnoses due to changes in CSM. We've been scrambling to try and qualify our AFTT patients under different primary diagnoses with AFTT as a comorbidity. Unfortunately we've had to live discharge a number of our AFTT patients as they had no other significant Comoros to qualify them under. I don't understand the change in CSM. Sometimes a patient has no significant Comorbs but are old, have stopped eating, are losing weight and are dying. We've been told that according to new CSM regs we can no longer qualify them as hospice appropriate even though we feel they have a 6 month prognosis or less. ***!

SuesquatchRN, BSN, RN · Jun 15, 2013

I've heard nothing about getting rid of dementia but AFTT and debility are on their ways out. They aren't diseases but syndromes and really, not every old person needs hospice.

EquestrianRN · Jun 17, 2013

I've heard nothing about getting rid of dementia but AFTT and debility are on their ways out. They aren't diseases but syndromes and really, not every old person needs hospice.

As a hospice RN, I actually can appreciate how the overuse of "debility" is viewed. It really IS too general. It is a syndrome, certainly, and not a "disease", as it were.

I have faced the same issues (obviously) regarding Medicare and their distaste for the listed, overused hospice-innitiating "diagnoses". The thing is that we, as admitting hospice nurses can simplify the process by utilizing the skill which should be inherent to us as professional nurses...DESCRIBING that which we SEE, using measurable universal guidelines which are not subjective, rather than oversimplifying, by simply TITLING a person with one syndrome or diagnosis name or another.

I say this because hospice corporate entities can readily utilize "Dx's" as a way to "slip a person into the system", thereby collecting reimbursement for a completely inappropriate patient to get on service.

With utilization of specifics, and defining what we as nurses are seeing, we can avoid any greed in the system from our end, also changing the manner through which hospice admissions coordinators are viewed by the medicare big wigs...

E.g. "Mr. Jones, a 69 year old caucasation male widower since approximately ten years ago, was diagnosed seven months ago with end-stage-renal-failure and end-stage liver-disease. Mr. Jones, with the appropriately emotional however complete support of his family, and, after discussing such with his pastor and friends, has elected to discontinue dialysis and other palliative therapies and come onto home hospice service at present, with the understanding that he may eventually require inpatient hospice care, for the following reasons:

At initial diagnosis, of renal and liver disease three years ago, the pt. was 5'9", and at a healthy weight of 190#. Pt was classified with a functional level of "high"; AEB still driving daily with no reported unsafe driving incidences per his daughter (who often rode in the car with him). Mr. Jones had been effectively completing all of his own grocery shopping, cooking, and house cleaning. He was, also, until approximately three months ago, maintaining his mental acuity very effectively through working daily crossword puzzles, reading novels, and volunteering once per week with an elder-literacy program.

As for maintaining his physiological strength and dexterity, again until about late March, he was actively gardening in his back yard every evening, and claims this was "also helpful for me before going to bed, as a means of relaxation". His gardening also was effectively acting towards promotion of heath, as it provided him with fresh, vegetables to eat as well, from his own garden.

Since discontinuing dialysis and since the diagnosis of liver disease was increased to end stage, his weekly labs reveal the following (include dates and all labs), his abdominal girth had gone from pre-hospice: (include measurement) to a current: (include measurement) due to ascites, despite weekly fluid taps beginning back on:( insert date), removing an average of 4 L of fluid with each procedure.

Pt is unable to drive or garden anymore due to "extreme weakness", as described by the patient. He has become significantly dyspneic due to the ascites, with ability to speak only four words, then pause, and continue with the sentence; generally pausing every three to five words to catch his breath.

He has been started on 2L 02 by NC as of two weeks ago, with minimal decrease in the level of dyspnea; now able to speak seven to nine words before pausing. The dyspnea as well as pressure from the ascites has effected his appetite greatly per pt. He is able only to consume one to two very small meals daily, and rather than heavy amounts of fresh veggies, his choice is to consume high calorie, fast food items which are easier to have delivered to him by his grandchildren.

His weight has declined to 150 # since two months ago. His muscle mass had dropped as well according to a pre-hospice measurement of ( ), & current measurement of: ( ).

He no longer drives, nor does he shop or clean for himself, as he is "too weak and I can't breathe well-enough to do any if it well enough to bother". He does not garden at all, as with the ascites, he says he cannot comfortably bend over whatsoever.

Pt does have a lot of emotional support, however, no one in his circle can devote the time needed to meet his at homecare and ADL needs, thus at this point, assisted living or care home are the only real options for pt. He understand this, and had been looking with his daughter for an appropriate gone, as well as, sadly, working to sell his own home.

**so...this should go on into greater measurable details in terms of a functional assessment Rather than writing "ESRF/ESLF" resulting in "DEBILITY" & eventually, "AFTT" as your diagnosis, the above gives medicare the needed MEAT to sink their teeth into! I cannot imagine any denial/questioning of services with that degree of info present; & realistically, I didn't even scratch the SURFACE in terms if what I WOULD WRITE were this gentleman an actual pt!

Anyhow, thank you for reading all of that! Just my... FORTY CENTS WORTH! Haha...

tewdles, RN · Jun 19, 2013

EquestrianRN, your post was worth more than $.40!!

NC29mom, ASN, LPN, RN · Jun 20, 2013

I forsee several hospice companies "going under" if they aren't able to use Debility/ AFTT. sadly, these are diagnosises used far too many times, and for inappropriate patients. I worked for a hospice cmpy once who had >75% of their pts under these diagnoses. They would admit a pt under Debility in a heartbeat. This same company also regularly admitted pts CURRENTLY in the hospital. Needless to say, due to their fraudulent practices, I saw myself out the door.

I think there are RARE cases in which Debility could be used (example: ES Parkinson's). However, because so many companies have abused these diagnoses, we can no longer use.

SuesquatchRN, BSN, RN · Jun 21, 2013

Equestrian, your description was fabulous but entirely unnecessary for anyone in end-stage renal disease who has discontinued dialysis. Automatic meeting of criteria. Just on the diagnosis.

tewdles, RN · Jun 21, 2013

I forsee several hospice companies "going under" if they aren't able to use Debility/ AFTT. sadly, these are diagnosises used far too many times, and for inappropriate patients. I worked for a hospice cmpy once who had >75% of their pts under these diagnoses. They would admit a pt under Debility in a heartbeat. This same company also regularly admitted pts CURRENTLY in the hospital. Needless to say, due to their fraudulent practices, I saw myself out the door.
I think there are RARE cases in which Debility could be used (example: ES Parkinson's). However, because so many companies have abused these diagnoses, we can no longer use.

In my view, those nurses and doctors were not doing their jobs. It would really seem unnecessary to have THAT high of a percentage of FTT or debility.