L31539 HOSPICE ALZHEIMER'S DISEASE & RELATED DISORDERS

 

 

Region IV J11AH-11-010-L

 

11/16/2012

 

• Alzheimer’s disease and related disorders may support a prognosis of six months or less under many clinical scenarios.

o The identification of specific structural/functional impairments, together with any relevant activity limitations, should serve as the basis for palliative interventions and care planning.

o The structural and functional impairments associated with a primary diagnosis of Alzheimer’s disease are often complicated by comorbid and/or secondary conditions.

o Comorbid conditions affecting beneficiaries with Alzheimer’s disease are by definition distinct from the Alzheimer’s disease itself- examples include coronary heart disease (CHD) and chronic obstructive pulmonary disease (COPD).

o Secondary conditions on the other hand are directly related to a primary condition – in the case of Alzheimer’s disease examples include delirium and pressure ulcers.

o The important roles of comorbid and secondary conditions are described below in order to facilitate their recognition and assist providers in documenting their impact.

• The Reisberg Functional Assessment Staging (FAST) Scale has been used for many years to describe Medicare beneficiaries with Alzheimer’s disease and a prognosis of six months or less.

o The FAST Scale is a 16-item scale designed to parallel the progressive activity limitations associated with Alzheimer’s disease.

o Stage 7 identifies the threshold of activity limitation that would support a six-month prognosis.

o The FAST Scale does not address the impact of comorbid and secondary conditions.

o These two variables are thus considered separately by this policy.

 

 

• FAST Scale Items:

o Stage #1: No difficulty, either subjectively or objectively

o Stage #2: Complains of forgetting location of objects; subjective work difficulties

o Stage #3: Decreased job functioning evident to coworkers; difficulty in traveling to new locations

o Stage #4: Decreased ability to perform complex tasks

 (e.g., planning dinner for guests; handling finances)

o Stage #5: Requires assistance in choosing proper clothing

o Stage #6: Decreased ability to dress, bathe, and toilet independently:

 Sub-stage 6a: Difficulty putting clothing on properly

 Sub-stage 6b: Unable to bath properly; may develop fear of bathing

 Sub-stage 6c: Inability to handle mechanics of toileting (i.e., forgets to flush, does not wipe properly)

 Sub-stage 6d: Urinary incontinence

 Sub-stage 6e: Fecal incontinence

o Stage #7: Loss of speech, locomotion, and consciousness:

 Sub-stage 7a: Ability to speak limited (1 to 5 words a day)

 Sub-stage 7b: All intelligible vocabulary lost

 Sub-stage 7c: Non-ambulatory

 Sub-stage 7d: Unable to sit up independently

 Sub-stage 7e: Unable to smile

 Sub-stage 7f: Unable to hold head up

 

 

• Comorbid Conditions:

o The significance of a given comorbid condition is best described by defining the structural/functional impairments - together with any limitation in activity - related to the comorbid condition.

o For example a beneficiary with Alzheimer’s disease and clinically significant CHD or COPD would have specific impairments of cardiorespiratory function (e.g., dyspnea, orthopnea, wheezing, and chest pain) which may or may not respond/be amenable to treatment.

o The identified impairments in cardiorespiratory function would be associated with both specific structural impairments of the coronary arteries or bronchial tree and may be associated with activity limitations

 (e.g., mobility, self-care).

o Ultimately, the combined effects of the Alzheimer’s disease (stage 7) and any comorbid condition should be such that most beneficiaries with Alzheimer’s disease and similar impairments would have a prognosis of six months or less.

 

 

• Secondary Conditions:

o Alzheimer’s disease may be complicated by secondary conditions.

 The significance of a given secondary condition is best described by defining the structural/functional impairments - together with any limitation in activity - related to the secondary condition.

 The occurrence of secondary conditions in beneficiaries with Alzheimer’s disease is facilitated by the presence of impairments in such body functions as mental functioning and movement functions.

 Such functional impairments contribute to the increased incidence of secondary conditions such as delirium and pressure ulcers observed in Medicare beneficiaries with Alzheimer’s disease.

 Secondary conditions themselves may be associated with a new set of structural/functional impairments that may or may not respond/be amenable to treatment. Ultimately, the combined effects of the Alzheimer’s disease (stage 7) and any secondary condition should be such that most beneficiaries with Alzheimer’s disease and similar impairments would have a prognosis of six months or less.

o The documentation of structural/functional impairments and activity limitations facilitate the selection of intervention strategies (palliative vs. curative) and provide objective criteria for determining the effects of such interventions.

 The documentation of these variables is thus essential in the determination of reasonable and necessary Medicare Hospice Services.

 

 

• Summary:

o For Beneficiaries with Alzheimer’s Disease to be eligible for hospice the individual should have a FAST level of greater than or equal to 7 and specific comorbid or secondary conditions meeting the above criteria.

 

 

Coding Information

 

Bill Type Codes:

 

• Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service.

• Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type.

• Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

 

081x Hospice (non-Hospital based)

082x Hospice (hospital based)

 

 

Revenue Codes:

 

• Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service.

• In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination.

• Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

 

0651  Hospice Service - Routine Home Care

0652  Hospice Service - Continuous Home Care

0655  Hospice Service - Inpatient Respite Care

0656  Hospice Service - General Inpatient Care Non-Respite

0657  Hospice Service - Physician Services

 

 

CPT/HCPCS Codes

 

HCPCS codes for applicable physician services

XX000 Not Applicable

 

 

ICD-9 Codes that Support Medical Necessity

 

290.3 SENILE DEMENTIA WITH DELIRIUM

294.21 DEMENTIA, UNSPECIFIED, WITH BEHAVIORAL DISTURBANCE

331.0 ALZHEIMER'S DISEASE

331.11 PICK'S DISEASE

331.2 SENILE DEGENERATION OF BRAIN

331.6 CORTICOBASAL DEGENERATION

 

 

Documentations Requirements

 

• Documentation certifying terminal status must contain enough information to confirm terminal status upon review.

o Documentation meeting the criteria listed under the Indications and Limitations of Coverage and/or Medical Necessity section of this LCD would contribute to this requirement.

o Recertification for hospice care requires that the same standards be met as for the initial certification.

• Documentation should be legible and made available to the A/B MAC upon request.

 

 

Sources of Information and Basis for Decision

 

Shuster JL Palliative Care for Advanced Dementia Clinics in Geriatric Medicine Volume 16, Number 2, May 2000

 

Committee on a National Agenda for the Prevention of Disabilities Disability in America: Toward A National Agenda for Prevention. National Academy Press, 1991(ISBN 0-309-04378-6)

 

Reisberg B Functional Assessment Staging (FAST). Psychopharmacology Bulletin. 24: 653-659, 1988

 

International Classification of Functioning, Disability and Health. Geneva: World Health Organization, 2001.

 

Hodges JR, Frontotemporal Dementia (Pick's Disease): Clinical Features and Assessment. Neurology, 56(11) June 2001

 

Kertesz, A., Munoz, D., Frontotemporal dementia. Medical Clinics of North America, 86(3), May 2002.

 

Geldmacher DS. Differential Diagnosis of Dementia Syndromes. Clinics in Geriatric Medicine, 20(1), February 2004

 

Local Coverage Determination (LCD) for Hospice Alzheimer's Disease & Related Disorders (L31539)