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You are here: Home / For Healthcare Providers / Yolo Hospice’s Medicare Evaluation Tools / Medicare Evaluation Tool | Pulmonary

Medicare Evaluation Tool | Pulmonary

Diagnosis: Pulmonary Disease
Physician Name:*
Phone Number*
Patient Name*
Patient Information
Medicare requires documentation of need for hospice through prognostic data. Please supply that below:
Documentation
Both 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 Data
3. 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.*
- 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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