Patient must have 1 and 2

  1. Stage VII or beyond according to FAST[1] with all of the following:
    1. Inability to ambulate without assistance
    2. Inability to dress without assistance
    3. Urinary or fecal incontinence (intermittent or constant)
    4. No consistent meaningful/reality based verbal communication; stereotypical phrases or the ability to speak is limited to a few intelligible words
  2. Has had at least (1) of the following conditions within the past (12) months:
    1. Aspiration pneumonia
    2. Pyelonephritis or other upper urinary tract infection
    3. Septicemia
    4. Pressure ulcers, many and/or above stage 3
    5. Recurrent fever after antibiotics
    6. Inability to maintain sufficient fluid and calorie intake with 10% weight loss during the previous six months or serum albumin <2.5 gm/dl.

Hospice appropriate diagnoses (with supporting documentation):

  • Alzheimer’s disease (G30.9)
  • Cerebral lipidoses (E75.4)
  • Dementia with Lewy bodies (G31.83)
  • Dementia with Parkinsonism (G31.83)
  • Senile degeneration of the brain (G31.1)
  • Epilepsy (G40.A01-G40.A07)
  • Frontal dementia (G31.09)
  • Frontotemporal dementia (G31.09)
  • General paresis (syphilis) (A52.17)
  • Hepatolenticular degeneration (E83.00)
  • Huntington’s chorea (G10)
  • Jakob-Creutzfeldt disease
  • Multiple sclerosis
  • Pick’s disease of the brain (G31.01)
  • Polyarteritis nodosa (I75.029, I75.019)
  • Syphilis (A52.17)

[1] Refers to “Functional Assessment Scale,” see FAST Scale

See another guide:
CVA (Stroke)/Coma
Heart Disease/CHF (Congestive Heart Failure)
Huntington’s Disease
Liver Disease
Neurological Diseases (see list below)
      ALS (Amyotrophic Lateral Sclerosis)
      Muscular Dystrophy
      Myasthenia Gravis
      MS (Multiple Sclerosis)
Pulmonary Disease/COPD (Chronic Obstructive Pulmonary Disease)
Renal (Kidney) Failure

Frequent Co-Morbidity documentation requirements
Cachexia/Protein Calorie Malnutrition (Weight Loss)

Referenced Tables 
Palliative Performance Scale (PPS)
New York Heart Association (NYHA) Functional Classes
Functional Assessment Staging (FAST) Scale

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