Cardiopulmonary conditions are associated with impairments, activity
limitations, and disability. Their impact on any given individual depends on
the individual's overall health status. Health status includes measures of
functioning, physical illness, and mental well-being, as well as,
environmental factors, such as the availability of palliative care services.
The objective of this policy is to present a framework for identifying,
documenting, and communicating the unique health care needs of individuals
with cardiopulmonary conditions, and thus promote the overall goal of the
appropriate care for every person, every time.  
  
Cardiopulmonary conditions may support a prognosis of 6 months or less under
many clinical scenarios. Medicare rules and regulations addressing hospice
services 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. The identification of specific structural/functional
impairments, together with any relevant activity limitations, should serve as
the basis for palliative interventions and care planning. Use of the
International Classification of Functioning, Disability and Health (ICF) to
help identify and document the unique service needs of individuals with
cardiopulmonary conditions is suggested, but not required.  
  
The health status changes associated with cardiopulmonary conditions can be
characterized using categories contained in the ICF. The ICF contains domains
(e.g., structures of cardiovascular and respiratory systems, functions of the
cardiovascular and respiratory system, communication, mobility, and self-care)
that allow for a comprehensive description of an individual's health status
and service needs. Information addressing relevant ICF categories, defined
within each of these domains, should form the core of the clinical record and
be incorporated into the care plan, as appropriate.  
  
Additionally, the care plan may be impacted by relevant secondary and/or
comorbid conditions. Secondary conditions are directly related to a primary
condition. In the case of cardiopulmonary conditions, examples of secondary
conditions could include delirium, pneumonia, stasis ulcers, and pressure
ulcers. Comorbid conditions affecting beneficiaries with cardiopulmonary
conditions are, by definition, distinct from the primary condition itself. An
example of a comorbid condition would be end stage renal disease (ESRD).  
  
The important roles of secondary and comorbid conditions are described below,
in order to facilitate their recognition and assist providers in documenting
their impact. The identification and documentation of relevant secondary and
comorbid 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:**  
  
Cardiopulmonary conditions 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 and
restriction in participation related to the secondary condition. The
occurrence of secondary conditions in beneficiaries with cardiopulmonary
conditions results from the presence of impairments in such body functions as
heart/respiratory rate and rhythm, contraction force of ventricular muscles,
blood supply to the heart, sleep functions, and depth of respiration. These
impairments contribute to the increased incidence of secondary conditions,
such as delirium, pneumonia, stasis ulcers, and pressure ulcers observed in
Medicare beneficiaries with cardiopulmonary conditions. 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, in order to support a hospice plan of care, the combined effects
of the primary cardiopulmonary condition and any identified secondary
condition(s) should be such that most beneficiaries with the identified
impairments would have a prognosis of 6 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
and restriction in participation related to the comorbid condition. For
example, a beneficiary with a primary cardiopulmonary condition and ESRD could
have specific ESRD-related impairments of water, mineral and electrolyte
balance functions coexisting with the cardiopulmonary impairments associated
with the primary cardiopulmonary condition (e.g., aortic stenosis, chronic
obstructive pulmonary disease, or heart failure).  
  
Ultimately, in order to support a hospice plan of care, the combined effects
of the primary cardiopulmonary condition and any identified comorbid
condition(s), should be such that most beneficiaries with the identified
impairments would have a prognosis of 6 months or less.  
  
The documentation of structural/functional impairments and activity
limitations facilitate the selection of the most appropriate intervention
strategies (palliative/hospice versus long-term disease management), and
provide 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.