LCD Eligibility Requirements for Hospice: A Documentation Checklist

Why LCD Documentation Is the Foundation of Hospice Compliance

Local Coverage Determinations (LCDs) define the clinical criteria that a patient must meet for Medicare to consider hospice care reasonable and necessary.

Note: LCD criteria are clinical guidelines used to support documentation of terminal prognosis and should be interpreted alongside physician clinical judgment. Each MAC publishes LCDs for the most common hospice diagnoses, including cancer, heart failure, COPD, dementia, debility, liver disease, renal failure, stroke, and others. CMS reviewers evaluate your documentation against these criteria every time a claim is audited or an ADR is issued.

Eligibility documentation is not a one-time intake task. It is an ongoing clinical responsibility. Every recertification, every IDG meeting, and every significant change in the patient’s condition is an opportunity to either strengthen or inadvertently undermine the case for continued eligibility. Agencies that treat eligibility as a living part of the medical record, updated with measurable clinical data at every encounter, perform dramatically better on audit than those that rely on intake-era documentation.

Universal Documentation Checklist (All Diagnoses)

The following documentation requirements apply regardless of primary diagnosis:

• Certification of Terminal Illness (CTI) completed by the attending physician and hospice medical director, with the physician’s attestation that the patient’s prognosis is six months or less if the disease runs its normal course
• Face-to-face encounter completed by a hospice physician or NP within 30 days prior to each recertification beginning with the third benefit period, with a written narrative explaining why the clinical findings support continued eligibility
• Interdisciplinary Group (IDG) meeting notes documenting team review of the patient’s current condition, functional status, and care plan at least every 15 days
• Plan of care that is individualized, includes measurable goals, and is updated to reflect clinical changes
• Declining PPS or Karnofsky scores, which may support terminal prognosis when interpreted in the context of the overall clinical trajectory. Many long-stay patients demonstrate progressively lower functional scores over time; extended periods without documented decline require especially strong clinical context supporting continued eligibility.
• Evidence of measurable decline over time (weight loss, functional decline, increasing symptom burden, or disease progression) documented across at least two consecutive time points

Diagnosis-Specific Documentation Checklist

For non-cancer diagnoses, the medical record must specifically address the LCD criteria for that diagnosis. For heart failure, this includes current NYHA Class IV symptoms, an ejection fraction below 20% if available, and documentation of optimal medical management or the patient’s decision to forgo aggressive treatment. For COPD, the record should reflect FEV1 below 30% of predicted if available, supplemental oxygen dependence, and frequent hospitalizations or ER visits. For dementia, the FAST scale stage (7A or beyond), dependence in six or more ADLs, and a secondary complication such as aspiration pneumonia or a stage 3–4 pressure ulcer within the past year are key supporting criteria.

For all non-cancer diagnoses, the IDG meeting minutes and nursing visit notes must describe the patient’s current status in terms that map directly to the LCD criteria. A note that says “patient continues to decline” is not sufficient. The note must say “patient’s FAST stage has progressed to 7C, requiring total assistance for all ADLs; patient experienced aspiration event on 5/1/2026 treated conservatively per family wishes.”

Common Documentation Gaps That Trigger ADRs

The most frequent documentation deficiencies identified in hospice ADR and TPE reviews include: face-to-face encounter notes that describe the visit but do not include the required written narrative supporting continued eligibility; recertifications signed after the deadline; IDG meeting minutes that list team members present but do not document the clinical discussion; care plans that have not been updated since admission; and nursing visit notes that are templated and do not reflect the patient’s current status. Each of these gaps can be identified and corrected before a claim is submitted.