J1400: Prognosis

J1400: Prognosis

Item Rationale

Health-related Quality of Life

• Residents with conditions or diseases that may result in a life expectancy of less than 6 months have special needs and may benefit from palliative or hospice services in the nursing home.

Planning for Care

• If life expectancy is less than 6 months, interdisciplinary team care planning should be based on the resident’s preferences for goals and interventions of care whenever possible.

Steps for Assessment

1. Review the medical record for documentation by the physician that the resident’s condition or chronic disease may result in a life expectancy of less than 6 months, or that they have a terminal illness.

2. If the physician states that the resident’s life expectancy may be less than 6 months, request that they document this in the medical record. Do not code until there is documentation in the medical record.

3. Review the medical record to determine whether the resident is receiving hospice services.

Coding Instructions

• Code 0, no: if the medical record does not contain physician documentation that the resident is terminally ill and the resident is not receiving hospice services.

• Code 1, yes: if the medical record includes physician documentation: 1) that the resident is terminally ill; or 2) the resident is receiving hospice services.

Examples

1. Resident T has a diagnosis of heart failure. During the past few months, they have had three hospital admissions for acute heart failure. Their heart has become significantly weaker despite maximum treatment with medications and oxygen. Their physician has discussed their deteriorating condition with them and their family and has documented that their prognosis for survival beyond the next couple of months is poor.

Coding: J1400 would be coded 1, yes.

Rationale: The physician documented that their life expectancy is likely to be less than 6 months.

2. Resident J was diagnosed with non-small cell lung cancer that is metastatic to their bone. They are not a candidate for surgical or curative treatment. With their consent, Resident J has been referred to hospice by their physician, who documented that their life expectancy was less than 6 months.

Coding: J1400 would be coded 1, yes.

Rationale: The physician referred the resident to hospice and documented that their life expectancy is likely to be less than 6 months.

DEFINITIONS

CONDITION OR CHRONIC DISEASE THAT MAY RESULT IN A LIFE EXPECTANCY OF LESS THAN 6 MONTHS

In the physician’s judgment, the resident has a diagnosis or combination of clinicalconditions that have advanced (or will continue to deteriorate) to a point that the average resident with that level of illness would not be expected to survive more than 6 months. This judgment should be substantiated by a physician note. It can be difficult to pinpoint the exact life expectancy for a single resident. Physician judgment should be based on typical or average life expectancy of residents with similar level of disease burden as this resident.

HOSPICE SERVICES

A program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions. The hospice must be licensed by the state as a hospice provider and/or certified under the Medicare program as a hospice provider. Under the hospice program benefit regulations, a physician is required to document in the medical record a life expectancy of less than 6 months, so if a resident is on hospice the expectation is that the documentation is in the medical record.

TERMINALLY ILL

“Terminally ill” means that the individual has a medical prognosis that their life expectancy is 6 months or less if the illness runs its normal course.