Medicare criteria for hospice care reimbursement

"The certification of terminal illness of an individual who elects hospice shall be based on the physician's or medical director's clinical judgment regarding the normal course of the individual's illness."
    -- Department of Health and Human Services, Health Care Financing Administration, January, 2001

1. Progressive disease with increasing symptoms and/or worsening lab values and/or decreasing functional status and/or evidence of metastatic disease, particularly brain.
2. Stage IV at initial diagnosis;
   Stage III with pleural effusion; or
   State II with patient continuing to decline despite definitive therapy
3. Karnofsky Performance Status < 70 or
   Palliative Performance Score < 70%
4. Symptomology:
   • Pain
   • Dyspnea
   • Significant hemoptysis
   • Superior vena cava syndrome
   • Lymphangitic lung involvement
   • Recurrent pneumonia (two or more episodes in three months)
5. Laboratory abnormalities:
   • LDH > twice normal
   • Albumen < 2.5
   • Calcium > 14
6. Weight loss of five percent or more in the last three months due to progressive disease, or irreversible dysphagia or loss of appetite;
7. Presence of severe co-morbidities that contribute to a life expectancy of six months or less, including but not limited to:
   • Chronic obstructive pulmonary disease
   • Congestive heart failure
   • Diabetes mellitus
   • Neurologic disease (CVA, ALS, MS)
   • Renal failure
   • Liver disease
   • Acquired immune deficiency syndrome (AIDS)
   • Dementia
8. Recurrent disease after surgery/radiation/chemotherapy.