Hospice eligibility guidelines: adult failure to thrive and debility

What changed, and why it matters

In the fiscal year 2015 hospice payment rule, CMS stated that debility and adult failure to thrive are nonspecific, symptom-type diagnoses and are not to be used as the principal hospice diagnosis. Claims that report them as principal are returned to the provider. CMS also directed hospices to report all related and coexisting diagnoses on the claim.

The patient did not change. The coding did. An older adult with weight loss, falling function and several chronic conditions may well have a prognosis of six months or less. The task is to name what is driving the decline and to document it.

Historical indicators, now used as supporting evidence

Read this table together with the general decline indicators and the non-disease-specific baseline (functional status and dependence in activities of daily living) on the eligibility guidelines overview.

How to document the underlying condition

1. Step 1

   List every active serious condition

   Heart failure, chronic lung disease, dementia, chronic kidney disease, prior stroke, Parkinson's disease, malignancy, diabetes with complications, protein-calorie malnutrition.

2. Step 2

   Ask which one contributes most to the prognosis

   This is a clinical judgment. In frail older adults it is most often dementia, heart disease, cerebrovascular disease or chronic lung disease. It should be the condition you would expect to write on the death certificate as the underlying cause.

3. Step 3

   Compare against that diagnosis's guideline

   Use the matching page in the eligibility guidelines. The patient may not meet it fully. That is common in this group and is where the next step matters.

4. Step 4

   Document the combined burden

   Record the secondary conditions with their severity, the general decline indicators with dates and values, and the reasoning that ties them together into a prognosis of six months or less.

5. Step 5

   Record the patient's goals

   Include the decision to decline hospitalization, artificial nutrition or further workup, where that applies. It is part of why the illness will run its normal course.

Supporting documentation

• Weights over 6 to 12 months and body mass index. Albumin or prealbumin if already drawn.
• Serial PPS or KPS scores. Which activities of daily living need help and since when.
• Falls, infections, pressure injuries, hospitalizations and emergency visits in the past 12 months.
• Cognitive status, with a FAST stage if dementia is present.
• Intake described in portions, swallowing problems, and the response to any nutritional intervention.
• Workup done for reversible causes, and the patient's or family's decision about further workup.

Comorbidities carry the case

The LCD guidance also weighs comorbidities. The presence and severity of conditions such as chronic obstructive pulmonary disease, congestive heart failure, ischemic heart disease, diabetes, neurologic disease (stroke, ALS, multiple sclerosis, Parkinson's disease), renal failure, liver disease, malignancy, AIDS and dementia can support a prognosis of six months or less even when the primary diagnosis alone does not. Document each one with its current severity and how it limits the patient.

For these patients the comorbidity section is not a footnote. It is usually the core of the eligibility narrative.

Not sure? Call

These are the referrals clinicians hesitate over most, because no single number makes the case. Prognosis is rarely clear cut. If you are weighing a referral, call and talk the case through with a hospice nurse, or ask for a physician-to-physician conversation with our medical director. A call is not a referral and does not commit the patient to anything.

If the patient is not hospice eligible now, we will say so and tell you what we would watch for. Some patients are better served by palliative care first. When you are ready, use Refer a patient. The hospice medical director, with the attending physician if there is one, makes the certification decision under 42 CFR 418.22.

A page you can share with the family

Families usually describe this situation as a parent who is slowing down, eating less and needing more help. Our guide Is it time for hospice? lists signs worth raising with a doctor or nurse, in plain language. It does not give an eligibility verdict. You are welcome to share it.