L31541 HOSPICE THE ADULT FAILURE TO THRIVE SYNDROME

 

 

Region IV J11AH-11-012-L

 

11/29/2012

 

• The adult failure to thrive syndrome is characterized by unexplained weight loss, malnutrition and disability.1

o The syndrome has been associated with multiple primary conditions (e.g., infections and malignancies), but always includes two defining clinical elements, namely nutritional impairment and disability.

o The nutritional impairment and disability associated with the adult failure to thrive syndrome may be severe enough to impact on the patient’s short-term survival.

• The adult failure to thrive syndrome may manifest as an irreversible progression in the patient’s nutritional impairment/disability despite a trial of therapy

 (i.e., treatment intended to effect the primary condition responsible for the patient’s clinical presentation).

o The presence of comorbid conditions may hasten the patient’s clinical progression and as such should be identified and addressed. 2

o This hospice policy addresses those cases where reversible causes of severe nutritional impairment and disability (i.e., the adult failure to thrive syndrome) have been excluded.

• The Medicare Hospice Benefit is predicated upon physician-certification that an individual entitled to Part A of Medicare is terminally ill.

o An individual is considered to be terminally ill if the individual has a medical prognosis that his or her life expectancy is six months or less if the terminal illness runs its normal course. 3

o The medical criteria listed below would support a terminal prognosis for individuals with the adult failure to thrive syndrome.

o Medical criteria 1 and 2 are important indicators of nutritional and functional status respectively, and would thus support a terminal prognosis if met.

 The nutritional impairment associated with the adult failure to thrive syndrome should be severe enough to impact on a beneficiary's weight.

• It is expected that the Body Mass Index (BMI) of beneficiaries electing the Medicare Hospice Benefit for the adult failure to thrive syndrome will be below 22 kg/m 2 and that the patient is either declining enteral/parenteral nutritional support or has not responded to such nutritional support, despite an adequate caloric intake.

• BMI (kg/m 2)=703 x (weight in pounds) divided by (height in inches) 2

 The disability associated with the adult failure to thrive syndrome should be such that the individual is significantly disabled.

• Significant disability would be demonstrated by a Karnofsky or Palliative Performance Scale value less than or equal to 40%. 4

• Both the beneficiary's BMI and level of disability should be determined using measurements/observations made within six months (180 days) of the most recent certification/recertification date.

o If enteral nutritional support has been instituted prior to the election of the Hospice Medicare Benefit and will be continued, the BMI and level of disability should be determined using measurements/observations made at the time of the initial certification and at each subsequent recertification.

• At the time of recertification recumbent measurement(s) (anthropometry) such as mid-arm muscle area in cm 2 may be substituted for BMI with documentation as to why a BMI could not be measured.

o This information will be subject to review on a case by case basis.

• In the event a beneficiary presenting with a nutritional impairment and disability does not meet the medical criteria listed above, but is still thought to be eligible for the Medicare Hospice Benefit, an alternate diagnosis that best describes the clinical circumstances of the individual beneficiary should be selected (e.g. 783.21 "abnormal loss of weight" and 799.4 "Cachexia")

 

 

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

 

 

ICD-9 Codes that Support Medical Necessity

 

783.41 FAILURE TO THRIVE

783.7 ADULT FAILURE TO THRIVE

799.3 DEBILITY UNSPECIFIED

799.89 OTHER ILL-DEFINED CONDITIONS

799.9 OTHER UNKNOWN AND UNSPECIFIED CAUSE OF MORBIDITY OR MORTALITY

 

 

Documentations Requirements

 

• Documentation supporting the medical necessity should be legible, maintained in the patient’s medical record, and must be made available to the Intermediary upon request.

• Documentation certifying terminal status must contain sufficient information to confirm terminal status upon review. Documentation meeting the criteria outlined in the Indications and Limitations of Coverage and/or Medical Necessity section of this policy would support this requirement.

• While data collection instruments such as checklists may facilitate the evaluation of nutritional impairments and disability at the time of certification/recertification, the medical record should substantiate the degree of nutritional impairment/disability noted on such instruments.

• A current BMI determined using the beneficiary's height and weight measured:

o within six months (180 days) of the most recent certification/recertification date for beneficiaries without enteral nutritional support

o at the time of initial certification and at each subsequent recertification for beneficiaries receiving enteral nutritional support.

• If recumbent anthropometry is substituted for BMI at recertification the rationale should be documented.

• A current evaluation of the beneficiary's functional status demonstrating a level of disability equivalent to that described by a Karnofsky or Palliative Performance Scale value of less than or equal to 40%, determined:

o within a six month period (180 days) from the most recent certification/recertification date for beneficiaries with enteral nutritional support

o at the time of initial certification and at each subsequent recertification for beneficiaries receiving enteral nutritional support.

 

 

Sources of Information and Basis for Decision

 

1. Fried L and Walston J: Frailty and Failure to Thrive in Principles of Geriatric Medicine and Gerontology, Hazzard WR, Blass JP, Ettinger WH et al (eds); the McGraw Hill Companies, Inc., 1999.

 

2. Verdery RB: Clinical evaluation of failure to thrive in older people. Clin Geriatr Med. 1997 Nov;13(4):769-78.

 

3. Title XVIII-Health Insurance for the Aged and Disabled: Part C Miscellaneous Provisions; Section 1861(3)(A).

 

4. Anderson F, Downing GM, Hill J. et al: Palliative performance scale (PPS): A new tool. Journal of Palliative Care 12:1996;5-11..

 

5. Karnofsky, DA & Burchenal, JH. (1949). “The Clinical Evaluation of Chemotherapeutic Agents in Cancer.” In McLeod CM (Ed), Evaluation of Chemotherapeutic Agents. Columbia Univ Press, 1949. Page 196.

Article(s)

A50424 - Hospice: Documenting Weight Loss for Beneficiaries with Non-Neoplastic Conditions opens in new window

 

Local Coverage Determination (LCD) for Hospice The Adult Failure To Thrive Syndrome (L31541)