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.