Hospice Documentation Tips

Medicare coverage of hospice depends on a physician’s certification that an individual’s prognosis is a life expectancy of six months or less if the terminal illness runs its normal course. It is important that the medical records support the physician’s six month prognosis. Often, during a review of the medical records by the MAC, the documentation is found to be insufficient to support the terminal prognosis. In some cases, the medical record lacks documentation to show further decline, for example, decreased oral intake, weight loss or increasing signs and symptoms.

Since determination of decline presumes assessment of the patient’s status over time, it is essential that both baseline and follow-up determinations be reported where appropriate. Since weight loss due to decreasing oral intake is often a good predictor of decline, it is essential that hospice staff document this information in the hospice medical record. Obtaining and recording objective data is instrumental in showing the continual decline of a patient when the weight loss and decreased appetite is not caused by other factors such as medication. Patients that have ceased to show on-going decline or who have plateaued from a trajectory of decline may no longer meet hospice eligibility guidelines despite a significant need for custodial care.

Suggestions for Documentation

• Obtain and document the patient’s weight (when possible). If the patient resides in a facility where bed scales, Hoyer lifts or other means of weighing the patient are accessible, impress upon the staff the importance of obtaining weights routinely.
• Obtain anthropomorphic measurements such as, mid-arm circumference or abdominal girth on admission, in addition to weighing the patient (if possible). As the patient’s disease progresses, weighing the patient may not always be an option. Establishing baseline anthropomorphic measurements upon admission will provide objective data in which to show decline if weighing the patient no longer becomes an option.
• Document the patient’s oral intake. Inadequate oral intake documented by decreasing food portion consumption along with weight loss can often be indicators of decline when it is not caused by other factors. Using specific portion sizes or percentages of food intake is more descriptive than a general comment, such as “intake declining.”

Reviewed 8/2/2024