Neurological 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 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 neurological
conditions and thus promote the overall goal of the right care for every
person, every time.  
  
Neurological 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
neurological conditions is suggested, but not required.  
  
The health status changes associated with neurological conditions can be
characterized using categories contained in the ICF. The ICF contains domains
and categories (e.g., structures of the nervous system, mental functions,
sensory functions and pain, neuromusculoskeletal and movement related
functions, 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 and categories, 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 neurological conditions, examples of secondary
conditions could include dysphagia, pneumonia, and pressure ulcers. Comorbid
conditions affecting beneficiaries with neurological conditions are, by
definition, distinct from the primary condition itself, however, services
aimed at the comorbid condition may indeed be related to the palliation and/or
management of the terminal condition. An example of a comorbid condition would
be chronic obstructive pulmonary disease (COPD).  
  
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:**  
  
Neurological 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 neurological
conditions results from the presence of impairments in such body functions as
consciousness, attention, sequencing complex movements, ingestion (which
includes chewing, manipulation of food in the mouth, and swallowing), muscle
power, tone, and endurance. These impairments contribute to the increased
incidence of secondary conditions such as dysphagia, pneumonia, and pressure
ulcers observed in Medicare beneficiaries with neurological conditions.
Secondary conditions themselves may be associated with a new set of
structural/functional impairments that may or may not respond or be amenable
to treatment.  
  
Ultimately, in order to support a hospice plan of care, the combined effects
of the primary neurological 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 neurological condition such as
amyotrophic lateral sclerosis (ALS) and a comorbidity of COPD could have
specific COPD-related structural and functional impairments of respiration
(e.g., structural impairments of the bronchoalveolar tree resulting in
increased respiratory rate, cough and impaired gas exchange) that contribute
to the activity limitations and participation restrictions already present due
to the respiratory muscle weakness often observed with ALS.  
  
Such a combination could affect the palliative care plan by contributing to
the individual's dyspnea and impaired exercise tolerance. Further
description/documentation using the activities and participation component of
the ICF (e.g., mobility, self-care, and interpersonal interactions and
relationships), would help complete the clinical picture. Palliative care
aimed at relieving the dyspnea and improving the individual's health status
would be the goal.  
  
Ultimately, in order to support a hospice plan of care, the combined effects
of the primary neurologic 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, together with the observed activity
limitations, facilitate the selection of the most appropriate intervention
strategies (palliative/hospice vs. 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.