Medicare Diagnosis Changes

Specialties Hospice

Published

Hi All,

I got the following message from NAHC regarding proposed CMS changes:

NAHC is reporting that in the CMS Open Door Forum held on May 8, CMS indicated thatin the future they will be returning claims to Hospice providers for certain diagnosis codes. It appears CMS is explicitly stating that it does not consider debility, failure to thrive, dementia and other similar diagnosisc odes to be appropriate as a principal diagnosis code for hospice claims. NAHC is recommending that that all hospices review each case where these diagnosis codes are listed as the principle diagnosis. Agencies should also be reporting all related co-morbidity diagnosis codes on their claims."

Has anyone heard anything further? This is concerning since there are patients who truly only qualify under one of these 3 diagnoses.

It seems like "protein calorie malnutrition" might be the new "debility"?

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Specializes in LTC, Sub-Acute, Hopsice.

The problem with "protein calorie malnutrition" would seem to be that it is also more of a syndrome, or symptom...what is causing it? "Debility" should be allowed to a very small extent. Like an above poster said, what about the little old lady who is just basically dying, but of no specific cause? Admittedly, that really is few and far between, but I have seen it a couple of times a year...just failing with no comoribidites, not having had treatment for cardiac, lung, kidney, liver etc. and no cancer, and none found with new testing. Those are the ones that "debility" or AFTT are for. Not the ones that have obvious, but not quite hospice-level diseases...the COPDer who is not O2 dependent, the cardiac pt with few obvious symptoms, but both may have shown decline in the past few months. Those need monitoring for a period of time, and maybe repeated re-evaluations to see if they now qualify. But many companies, including mine, had gotten so used to saying "admit them with debility and maybe we can change the dx later, when something gets worse". That's how you get such long lengths of stay, not a good thing.

I personally am glad that we no longer are able to use AFTT or Debility. I know it will take a lot more brain power on my part during admission/evaluation visits, and prior to admission we may need to get more info from hospitals and MDs, but I feel it is worth it. I have had patients that I dreaded doing re-certifications because they just didn't seem to decline as I thought they should have, and have had close to shouting matches with my DON when I didn't think a patient should be admitted (or re-certified).

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Hi All,

I have read and reread the Federal Register from CMS that was released 8/7/13 with the final rule on these diagnoses...and it is very vague for Dementia. On one hand it looks like they don't want us to use Dementia as a primary dx at all, and on the other hand it seems like it is okay as long as there is not a more appropriate (ie. cancer) dx that should have been listed primary. The report states that many hospices have listed dementia as a primary dx without listing ANY secondaries, and I think that is their issue. Has anyone else reviewed it? If so how have you or your organization interpreted it? Last week I admitted a patient with a primary dx of anorexia and a secondary of dementia and dysphagia to be safe, per the recommendation of the MD. This goes against what I have always done...listed the underlying cause of the anorexia and dysphagia as primary...DEMENTIA! Just wondering what everyone else is doing?

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Specializes in Hospice, Geriatrics, Wounds.

Medicare requested all applicable comorbidities be listed several yrs ago. The LCD's do say pts with dementia should have comorbidities to be eligible. However, these are just guidelines.

Wow. So pts attending & your medical director both certified your pt would be dead in 6m from anorexia? It sounds more like a secondary condition to me, not an actual primary diagnosis

We still admit with dementia ;however the cmpy I work for was not one to openly/fraudulently admit pts with dementia unless very appropriate to begin with.

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NC29mom I am referring to the most recent updates from CMS and looking for help from those who have read them. I understand that comorbs should be listed, my question is a matter of the primary dx. I also do not work for a company that fraudently admits dementia patients, I just want to be up to date with the regulations. Thanks

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I am in a hh transitional program. Who is organizing a protest/petition/mass letter? Can we get this started here? Interested? I am... Who would we send it to? Cms? Local govt? I seem to recall either texas or florida getting hospice benefit cancellation overturned for medical patients...,

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I am in a hh transitional program. Who is organizing a protest/petition/mass letter? Can we get this started here? Interested? I am... Who would we send it to? Cms? Local govt? I seem to recall either texas or florida getting hospice benefit cancellation overturned for medical patients...,

I am not. Personally, they are overused diagnoses. Dying does not equal a need for hospice. I agree that hospice is now used when not necessary. Old age and infirmity should not be an automatic hospice admission. Even though there are a lot of bonuses to be made from it.

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I am not. Personally, they are overused diagnoses. Dying does not equal a need for hospice. I agree that hospice is now used when not necessary. Old age and infirmity should not be an automatic hospice admission. Even though there are a lot of bonuses to be made from it.

Except for when patients actually do qualify... Should patients suffer and take the hit for fraudulent agencies? Not fair in my opinion...isnt that why they have follow up evaluations and dc if no further decline?

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Except for when patients actually do qualify... Should patients suffer and take the hit for fraudulent agencies? Not fair in my opinion...isnt that why they have follow up evaluations and dc if no further decline?

But if they do not meet CMS criteria they do NOT actually qualify. We are working like maniacs to get people off of the now questionable diagnoses and NO ONE who qualifies for hospice doesn't have an entire set of comorbs that are far clearer than debility. I have not had to d/c a single one of my patients because I couldn't find a better diagnosis. And if you can't find something more than that he is frail and dying that does not qualify for hospice. Death is not unnatural and does not automatically require skilled nursing intervention.

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Specializes in Hospice, Geriatrics, Wounds.

I agree.... .overused and abused. And, I personally agree with the change. A local hospice used debility for >75% of its admissions, which makes it hard for the hospice companies who are legit. I'm sorry....

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Specializes in LTC, Sub-Acute, Hopsice.

I too agreed with getting rid of debility...until this weekend when I did an evaluation on a man who would have fit debility perfectly but had no other documented diagnosis to meet eligibility. Granted, if I had had more health history and MD notes, and if the MD had returned my phone calls for more info, it might have been a different story.

For the most part, I think debility was so overused and I'm surprised it took CMS so long to drop it. But there are still 95 year olds out there with no real co-morbidities who are just dying from old age...and at times it is impossible to find them eligible for hospice.

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