Hospice care is designed for patients in the final stages of a terminal illness who are no longer seeking curative treatment. To qualify for hospice under Medicare and most insurance plans, patients must meet specific eligibility criteria that demonstrate a prognosis of six months or less if the disease runs its natural course.
But here’s the challenge: eligibility isn’t determined by a single test or diagnosis. It is supported by clear, ongoing documentation of decline. For hospice agencies, effective documentation is not just about compliance—it’s about ensuring patients receive the care they need at the right time, avoiding denials, and protecting the agency during audits or surveys.
In this article, we’ll explore hospice eligibility criteria, the importance of documenting decline, and practical strategies for charting effectively.
Understanding Hospice Eligibility Criteria
The Six-Month Prognosis Requirement
Medicare requires that two physicians (usually the attending physician and the hospice medical director) certify that the patient has a life expectancy of six months or less. This is based on the patient’s disease trajectory, functional status, and clinical indicators.
The Role of LCDs (Local Coverage Determinations)
The Centers for Medicare & Medicaid Services (CMS) provides Local Coverage Determinations (LCDs) that outline disease-specific criteria for hospice eligibility. These guidelines exist for conditions like cancer, dementia, heart disease, lung disease, stroke, renal failure, and liver disease.
For example:
Dementia (per LCD): FAST scale stage 7 or beyond, with complications such as weight loss, recurrent infections, or pressure ulcers.
Heart disease: Optimally treated patients with NYHA Class IV symptoms, frequent hospitalizations, or ejection fraction <20%.
Pulmonary disease: Dyspnea at rest, oxygen dependency, frequent infections, or unintentional weight loss.
Non-Disease-Specific Decline
CMS also recognizes general decline indicators such as:
Progressive weight loss (>10% over six months).
Functional decline in Activities of Daily Living (ADLs).
Increased frequency of ER visits or hospitalizations.
Reduced oral intake, increased sleeping, or decreased responsiveness.
Why Documentation of Decline Matters
Compliance and Survey Readiness
Hospice agencies are routinely audited by Medicare Administrative Contractors (MACs). Inadequate documentation is one of the top reasons for claim denials.
Clinical Accuracy and Continuity of Care
Clear documentation ensures that the entire interdisciplinary team (IDG)—nurses, physicians, social workers, and chaplains—understands the patient’s condition and trajectory.
Protecting the Agency
Incomplete or vague charting exposes agencies to penalties, repayment demands, or even suspension of Medicare certification.
Supporting Families
Families rely on documentation to understand why hospice is appropriate and to see evidence of their loved one’s decline.
Mistakes Agencies Make in Documenting Decline
Copy-and-Paste Charting: Repeating the same notes week after week suggests the patient is stable, even if decline is happening.
Lack of Specificity: Writing “patient appears weaker” is not enough; details are needed.
Focusing on Stability Instead of Decline: Highlighting improvement or unchanged status without framing decline can make patients appear ineligible.
Ignoring Non-Physical Decline: Decline isn’t just weight loss—it includes cognition, function, and psychosocial changes.
Overly Positive Wording: Phrases like “patient doing well” or “improved appetite” should be carefully reframed to show the broader decline trajectory.
How to Document Decline Effectively
1. Use Objective Measurements
Weight and BMI: Record exact numbers, not vague statements. Example: “Weight decreased from 120 lbs to 110 lbs in two months (8% loss).”
Vital Signs: Document trends such as low oxygen saturation despite supplemental oxygen.
Functional Scales: Use standardized tools like:
2. Capture Disease-Specific and Non-Specific Indicators
Disease-Specific Example: COPD patient with O2 sat at 84% on 4L NC, unable to ambulate more than a few steps.
Non-Specific Example: Patient now sleeps 18 hours/day, eats less than 25% of meals, requires total assistance with bathing and toileting.
3. Write in Comparative Language
Show progression by comparing current status to past visits:
“Last month, patient was able to feed self with assistance. Now requires staff to feed all meals.”
“Previously oriented x2, now oriented only to self.”
4. Document Psychosocial and Cognitive Decline
Increased confusion or agitation.
Withdrawal from family interactions.
Inability to recognize caregivers.
Frequent tearfulness or expressions of hopelessness.
5. Highlight Interventions and Responses
Document what the team is doing and how the patient responds:
“Pain managed with morphine, but patient now requires scheduled doses every 4 hours instead of PRN.”
“Despite nutritional supplements, patient continues to lose weight.”
6. Avoid “Stable” Language
Even if symptoms are managed, decline is often still present. Instead of:
❌ “Patient stable on oxygen.”
Use:
✅ “Patient requires continuous 5L O2 at rest, with progressive decline in mobility compared to prior visit.”
7. Use Narrative Examples
Surveyors value real-life observations:
“Patient seen in bed, unable to reposition self, grimaced when turned, and required assistance for hygiene.”
“Daughter reports patient has not spoken for 3 days and eats only bites of applesauce daily.”
Tools to Support Documentation
EMR Templates: Many hospice EMRs (Axxess, MatrixCare, Homecare Homebase) offer built-in LCD criteria prompts.
Checklists and Flow Sheets: Helps staff ensure all decline markers are covered.
IDG Notes: Team narratives should reinforce decline across disciplines.
Ongoing Education: Train staff regularly on LCDs, documentation best practices, and compliance updates.
Case Examples
Case 1: Dementia Patient
Poor Documentation: “Patient confused, needs assistance.”
Effective Documentation: “Patient unable to recognize family members, oriented only to self. Now requires total assistance with bathing, dressing, and toileting. Weight has dropped from 145 lbs to 130 lbs in 4 months (10% loss). Previously able to walk with walker, now wheelchair-bound.”
Case 2: CHF Patient
Poor Documentation: “Patient doing okay, shortness of breath continues.”
Effective Documentation: “Patient experiences dyspnea at rest, oxygen saturation 85% on 3L O2. Requires assistance for ADLs. Two ER visits in the last month for CHF exacerbations. No longer able to climb stairs or prepare meals.”
Best Practices for Hospice Teams
Interdisciplinary Consistency: Nurses, social workers, and chaplains should all describe decline in their notes.
Regular Updates: Document changes at each visit—don’t wait until recertification.
Family Input: Include caregiver observations (“family reports patient eats less than one meal/day”).
Education: Teach staff that documenting decline is not “negative”—it is a clinical requirement.
Audit and Feedback: Supervisors should review charts regularly and provide coaching.
Conclusion
Documenting decline effectively is one of the most important responsibilities of hospice agencies. It ensures:
Patients receive timely access to hospice.
Agencies remain compliant with Medicare and insurance requirements.
Families understand the appropriateness of hospice care.
By using objective data, comparative language, disease-specific criteria, and narrative observations, hospice teams can paint a clear, accurate picture of decline that supports eligibility and demonstrates compassionate, high-quality care.
Remember: good documentation tells the story of decline—not just the services provided.
