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LCD Criteria for Hospice Patients in a Coma

It is important for hospices to understand that Medicare Administrative Contractors (MACs), Cigna Government Services (CGS), National Government Services (NGS), and Palmetto set disease-specific criteria for eligibility for coma that include assessing the non-disease specific criteria alongside the disease-specific criteria. As with all hospice patient diagnoses, eligibility is ultimately determined by the physician’s narrative statement in the Certification of Terminal Illness (CTI) including specific reasons along with these Local Coverage Determination (LCD) criteria. Physicians must believe that the patient has a prognosis of six months or less if the disease runs its expected course.

Understanding the LCD Criteria

CGS and NGS have very specific criteria for patients with a terminal diagnosis of coma. These criteria are important regardless of the coma’s underlying cause. The MACs are looking for three of the following responses – or lack of responses – on the third day after the coma has started:

  • Abnormal brain stem response
  • Absent verbal response
  • Absent withdrawal response to pain
  • Serum creatinine >1.5 mg/dl.

In addition, NGS and CGS request, but do not require, the presence of the following medical complications in the last 12 months:

  • Aspiration pneumonia
  • Upper urinary tract infection
  • Sepsis (CGS only)
  • Refractory stage 3-4 pressure ulcers
  • Fever recurrent after antibiotics.

Diagnostic CT scans are especially helpful for indicating poor prognosis with coma from a stroke. In non-traumatic hemorrhagic (bleeding) strokes, CGS and NGS are looking for the presence of large volume hemorrhages, ventricular extension of hemorrhages, large surface area hemorrhages, midline shifts, or obstructive hydrocephalus without ventriculoperitoneal shunt placement.

For thrombotic/embolic (clot) strokes, CGS and NGS are looking for confirmation of the presence of large areas of loss of brain function on both sides of the brain or with both cortical and subcortical infarcts, basilar arterial occlusion, or bilateral vertebral artery occlusion. For new strokes, it is very helpful to verify severity by obtaining CT scans from the hospital stay when the stroke occurred.

Palmetto discusses all neurological conditions (except dementia/Alzheimer’s disease) in one LCD. If Palmetto is your MAC, your hospice software documentation must have significant information on the presence of comorbidities and secondary conditions that impact the plan of care by adding to symptom burden, functional decline, activity limitations, and ultimately the overall prognosis. Secondary conditions are directly related to and caused by the terminal diagnosis. An example would be a patient with a coma who has resultant dysphagia and pressure ulcers from poor mobility and deficient nutritional intake. Comorbid conditions are distinct from the terminal disease itself but impact the functional status and decline. An example of this would be a patient with a coma who also has COPD is more at risk for pneumonia due to the underlying pulmonary disease process. The combination of terminal disease, secondary conditions, and comorbidities impact the prognosis of a patient and should be addressed in the CTI narrative.

All MACs expect the hospice to determine the diagnoses that are related to the patient’s terminal prognosis and address them in the CTI narrative to accurately illustrate 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 to address the patient’s needs currently and during the hospice admission.

Documenting the Correct Information

Obtaining as much medical history from the hospital where the patient started the comatose state is very useful for documenting eligibility for hospice care. Documentation regarding the underlying cause of the coma, if known, will help bolster the claim that the patient is in fact entering the terminal, rather than chronic, phase of illness. This documentation can be done using Axxess Hospice.


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