Medicare Evaluation Tool | Liver Disease

Liver Disease - MED EVAL TOOLS

Diagnosis: Liver Disease
Physician Name*
Phone Number*
Patient Name*
Patient Information
Medicare requires documentation of need for hospice through prognostic data. Please supply that below:
Patient with:*
- The patient has Prothrombin time prolonged more than 5 sec. over control, or INR > 1.5 and Serum Albumin < 2.5 gm/dl.
AND at least one of the following:*
Check all that apply:
- Ascites, refractory to treatment or patient non-compliant
- Spontaneous bacterial peritonitis
- Hepatic encephalopathy, refractory to treatment or patient non-compliant
- Recurrent variceal bleeding, despite intensive therapy
Supporting Data*
Check all that apply:
- Progressive malnutrition
- Muscle wasting with reduced strength and endurance
- HBsAg (Hepatitis B) positivity
- Hepatitis C refractory to interferon
- Hepatocellular carcinoma
- Continued alcoholism (>80 gm ethanol/day)
- Bilirubin, albumin, other liver enzyme levels abnormal
- None of the above
Other*
Please specify:
Please respond YES or NO to the statements in this section:
I support hospice care for this patient.*
- Yes
- No
I will be patient’s attending physician.*
- Yes
- No
I have discussed hospice with patient/loved ones.*
- Yes
- No
I have discussed terminal diagnosis when it becomes necessary.*
- Yes
- No
I will sign death certificate when it becomes necessary.*
- Yes
- No
- 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
Name
This field is for validation purposes and should be left unchanged.

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Diagnosis: Liver Disease

Patient Information

Please respond YES or NO to the statements in this section:

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