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Local Coverage Determination for Alzheimer’s and Related Disorders

The Medicare Administrative Contractors (MACs) Cigna Government Services (CGS), National Government Services (NGS), and Palmetto set disease-specific eligibility criteria for Alzheimer’s Disease and related disorders that include assessing the non-disease specific criteria alongside the disease-specific criteria.

With Alzheimer’s Disease and other related dementia diagnoses, the determination of a six-month prognosis can be especially challenging for agencies, and often can result in long lengths of stay on hospice. Using the MACs’ eligibility criteria can help hospice agencies determine on admission and throughout the hospice stay where a patient lies on the disease trajectory.

Using the FAST Scale Is Essential

All MACs use the Functional Assessment Staging Test (FAST) as a determining factor for eligibility. The FAST scale is a 16-item scale designed to document the progressive activity deficits associated with Alzheimer’s Disease. Stage 7a identifies the threshold of activity deficit that would support a six-month prognosis for hospice eligibility. The FAST scale staging for end-stages of Alzheimer’s Disease is as follows:

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

  • Sub-stage 6a: Difficulty putting clothing on properly
  • Sub-stage 6b: Inability to bathe properly; may develop a fear of bathing
  • Sub-stage 6c: Inability to handle mechanics of toileting (e.g., forgets to flush, does not wipe properly)
  • Sub-stage 6d: Urinary incontinence
  • Sub-stage 6e: Fecal incontinence

Stage 7: Loss of speech, locomotion, and consciousness

  • Sub-stage 7a: Limited ability to speak (five to six 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

Can the FAST Scale Only Be Used for Alzheimer’s Patients?

There is debate among hospice providers as to if the FAST scale can be used for non-Alzheimer’s dementia progression. The FAST scale is validated for Alzheimer’s Disease progression, as patients with Alzheimer’s Disease follow the scale’s progression in that order. Patients with other types of dementia may not follow the linear progression of the FAST scale in the same way. NGS and CGS specify in their LCDs that the FAST scale is only appropriate for Alzheimer’s Disease and related disorders, and not for other types of dementia, such as multi-infarct dementia.

Recognition of these differences in your documentation assists with any potential documentation irregularities if a patient does not show a progression of the FAST scale in order. If the patient does not have Alzheimer’s Disease as a diagnosis, the FAST scale score will possibly not be an accurate predictor of prognosis.

Comorbidities and Secondary Conditions Are Relevant

The FAST scale also does not address the impact of comorbidities and secondary conditions. This means if a patient has a significant decline in mental status that corresponds to a significant medical change, such as an infection or dehydration, the patient may appear to have a lower FAST scale at that moment. To account for this, ask about how the patient was performing according to the FAST scale criteria six months earlier and just before the precipitating events that led to the hospice referral.

NGS and CGS both specify the need for the presence of the following secondary conditions of specific infections and conditions in the 12 months prior to the evaluation for eligibility:

  • Aspiration pneumonia;
  • Pyelonephritis or other upper urinary tract infections;
  • Septicemia;
  • Decubitus ulcers, multiple, stage 3-4;
  • Fever, recurrent after antibiotics;
  • Inability to maintain sufficient fluid and calorie intake with 10% weight loss during the previous six months or serum albumin of less than 2.5 gm/dl.

Palmetto also specifies the secondary conditions (conditions related to and caused by the terminal diagnosis) as being relevant, in that the lack of cognitive functioning and impaired mobility cause these conditions and are indicative of end-stage disease. Comorbid conditions, which are distinct from the terminal disease itself but impact the functional status and decline, are also important to eligibility for all MACs. The presence of pulmonary, cardiac, or other significant diseases can impact the patient’s baseline status, as well as contribute to the symptom burden and prognosis of Alzheimer’s Disease and related disorders.

Determining the Full Diagnoses Will Lead to Better Care

All MACs expect the hospice to determine the diagnoses that are related to the patient’s terminal prognosis and address all in the Certification of Terminal Illness (CTI) narrative to accurately illustrate the reasons the physician believes the patient has a prognosis of six months or less. Furthermore, accurately identifying and assessing the patient’s full diagnoses will assist agencies with developing the most accurate and proactive plan of care for addressing the patient’s needs at the present time and during the hospice admission.

Determining prognosis for Alzheimer’s Disease and related disorders can be challenging, as the patients can appear to have symptoms managed for long periods of time between secondary condition occurrences. Documenting the decline in the hospice software according to the LCDs with a thorough CTI narrative detailing the impact of comorbid conditions will help agencies withstand regulatory scrutiny for long length of stay patients. Axxess offers a library of useful blogs to help your hospice agency provide exceptional care.


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