Liver disease is one of the only diagnoses for which the Medicare Administrative Contractors (MACs) Cigna Government Services (CGS), National Government Services (NGS), and Palmetto, have set laboratory value guidelines to determine eligibility for hospice services. These values and comorbidities assist with determining when a patient is going from chronic disease management to end-of-life care. As with all diagnoses, a patient may be declined for coverage if the LCD criteria is not met. However, the patient may still be approved for coverage if there is documentation of significant comorbidities or a rapid decline.
Guidelines for Coverage
All the MACs agree on what laboratory results, secondary conditions, and supporting factors need to be documented in your hospice software for liver disease LCDs. If you do not have labs, and it is an emergency admission situation, it is best for your agency to obtain a serum albumin and prothrombin time (PT) as soon as possible after admission. This practice will help your agency withstand an Additional Development Request (ADR). If your agency chooses to admit a patient on the liver transplant list, the MACs agree that this is acceptable if the patient comes off hospice services prior to the transplant. It is important to note that your agency will likely be responsible for the payment of physician appointments and laboratory monitoring related to liver disease and liver transplant list qualifications.
To be considered in the terminal stage of liver disease, several things must happen. First, both a PT of more than five seconds over control or International Normalized Ratio (INR) greater than 1.5, as well as serum albumin of less than 2.5gm/dl should be present. While CGS mentions they want to see serum albumin, they do not specify the value they wish to have documented. Next, the presence of one of the following secondary conditions lend supporting documentation of the terminal prognosis:
- Ascites, refractory to treatment or patient non-compliant
- Spontaneous bacterial peritonitis
- Hepatorenal syndrome – elevated creatinine and BUN with oliguria (< 400 ml/day) and urine sodium concentration (less than 10 mEq/l, per Palmetto and NGS)
- Hepatic encephalopathy, refractory to treatment, or patient non-compliant
- Recurrent variceal bleeding, despite intensive therapy
Lastly, documentation of the presence of any of the following factors will support eligibility:
- Progressive malnutrition
- Muscle wasting with reduced strength and endurance
- Continued active alcoholism (>80 gm ethanol/day) – a calculator for grams of alcohol is here, and generally, each standard alcoholic drink is 14 grams of ethanol
- Hepatocellular carcinoma
- HBsAg (Hepatitis B) positivity
- Hepatitis C refractory to interferon treatment
For the best chance of having your patient’s documentation clear through an ADR, try to obtain as many hospital or outpatient labs as possible, along with documentation of the secondary conditions. Liver disease can be a long chronic disease trajectory, so as much documentation that can be obtained of the above-named factors will strengthen your ability to prove eligibility.
All MACs expect the hospice to determine the diagnoses that are related to the patient’s terminal prognosis and address all in the CTI narrative to accurately paint the picture of reasons the physician believes the patient has a prognosis of six months or less. Accurately identifying and assessing the patient’s full diagnoses will assist agencies with developing a proactive Plan of Care for addressing the patient’s needs during hospice care.
Obtaining as much medical history and laboratory data from hospitals where the patient has been treated for liver disease is very useful for documenting eligibility for hospice care. Laboratory studies for PT and serum albumin throughout a long-length stay in hospice will also help document continued eligibility for hospice services.