Medicare Evaluation Tool | Pulmonary Diagnosis: Pulmonary DiseasePhysician Name:*Phone Number*Patient Name*Patient InformationMedicare requires documentation of need for hospice through prognostic data. Please supply that below:DocumentationBoth 1 and 2 below should be present. Factors from 3 help support the prognosis.1. Severe chronic lung disease as documented by both A and B:* A – Disabling dyspnea at rest, poor or unresponsive to bronchodilators, resulting in decreased functional capacity (e.g., bed-to-chair existence, fatigue, and cough.) Documentation of FEV1, after bronchodilator, less than 30% of predicted is objective evidence for disabling dyspnea, but is not required. B – Progression of end stage pulmonary disease, as evidenced by increasing ER visits or hospitalizations for pulmonary infections and/or respiratory failure or increased physician home visits prior to initial certification. Documentation of serial decrease of FEV1>40ml a year is objective evidence of disease progression, but is not required. 2. Hypoxemia at rest on room air, as evidenced by p02≤55mmHg; or 02 saturation≤88%, determined either by arterial blood gases, oxygen saturation monitors or hypercapnia as evidenced by pCO250mmHg,50mmHg This information may be obtained from recent (within 3 months) hospital records.* Present Supporting Data3. The following factors also lend support to a terminal diagnosis of pulmonary disease. Document them if they are present.Factors: Right heart failure (RHF) secondary to pulmonary disease (cor pulmonale) Unintentional progressive weight loss of greater than 10% of body weight over the preceding six months. Resting tachycardia >100/min Please respond YES or NO to the statements in this section:I support hospice care for this patient.*YesNoI will be patient’s attending physician.*YesNoI have discussed hospice with patient/loved ones.*YesNoI have discussed terminal diagnosis when it becomes necessary.*YesNoI will sign death certificate when it becomes necessary.*YesNo Based on the information indicated above, the above named patient has a medical prognosis that life expectancy is six (6) months or less, if the terminal illness runs its normal course. Digital Signature*Please enter your name below to serve as your electronic signature.Verification This iframe contains the logic required to handle Ajax powered Gravity Forms.