Summary Of Evidence

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Analysis of Evidence

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End stage renal disease (ESRD) may support a prognosis of six months or less under many clinical scenarios. The identification of specific structural/functional impairments, together with any relevant activity limitations, should serve as the basis for palliative interventions and care planning. The structural and functional impairments associated with a primary diagnosis of ESRD are often complicated by comorbid and/or secondary conditions. Comorbid conditions affecting beneficiaries with ESRD are by definition distinct from the ESRD itself- examples include vascular disease manifested as coronary heart disease (CHD), peripheral vascular disease (PVD), and vascular dementia. Secondary conditions, on the other hand, are directly related to a primary condition. In the case of ESRD, examples include secondary hyperparathyroidism, calciphylaxis, nephrogenic systemic fibrosis, electrolyte abnormalities and anorexia. The important roles of comorbid and secondary conditions are described below in order to facilitate their recognition and assist providers in documenting their impact. Use of the International Classification of Functioning, Disability and Health (ICF) is suggested, but not required.

Medicare rules and regulations require the documentation of sufficient “clinical information and other documentation” to support the certification of individuals as having a terminal illness with a life expectancy of 6 or fewer months, if the illness runs its normal course. For beneficiaries with ESRD the identification of relevant comorbid and secondary conditions, together with the identification and description of associated structural/functional impairments, activity limitations, and environmental factors would help establish hospice eligibility and maintain a beneficiary-centered plan of care.

Secondary Conditions:

ESRD may be complicated by secondary conditions. The significance of a given secondary condition is best described by defining the structural/functional impairments - together with any limitation in activity - related to the secondary condition. The occurrence of secondary conditions in beneficiaries with ESRD is facilitated by the presence of impairments in such body functions as urinary excretory function, water, mineral and electrolyte function, and endocrine gland functions. Such functional impairments contribute to the increased incidence of secondary conditions such as hyperkalemia, fluid overload, and secondary hyperparathyroidism observed in Medicare beneficiaries with ESRD. Secondary conditions themselves may be associated with a new set of structural/functional impairments that may or may not respond/be amenable to treatment. Ultimately, the combined effects of the ESRD and any secondary condition should be such that most beneficiaries with ESRD and similar impairments would have a prognosis of six months or less.


Comorbid Conditions:

The significance of a given comorbid condition is best described by defining the structural/functional impairments - together with any limitation in activity - related to the comorbid condition. For example, a beneficiary with ESRD and clinically significant CHD would have specific impairments of cardiovascular structure/function (e.g., narrowing of coronary arteries, dyspnea, orthopnea, chest pain) which may or may not respond/be amenable to treatment. The identified impairments in cardiovascular structure/function may be associated with activity limitations (e.g., mobility, self-care). Ultimately, the combined effects of the ESRD and any comorbid condition should be such that most beneficiaries with ESRD and similar impairments would have a prognosis of six months or less.

The documentation of structural/functional impairments and activity limitations facilitates the selection of intervention strategies (palliative vs. long-term disease management/curative) and provides objective criteria for determining the effects of such interventions. The documentation of these variables is thus essential in the determination of reasonable and necessary Medicare hospice services.