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For Physicians: Documentation Requirements
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Documentation Requirements

Documentation certifying terminal status must contain enough information to support terminal status upon review. Documentation of the applicable criteria listed under the "Indications” section of the LCD would meet this requirement. If other clinical indicators of decline not listed in the LCD such as psychological and spiritual factors form the basis for certifying terminal status, they should be documented as well. Recertification for hospice care requires the same clinical standards be met as for initial certification, but they need not be reiterated. They may be incorporated by specific reference as part (or all) of the indication for recertification.

Documentation should "paint a picture” to clearly see why the patient is appropriate for hospice care. The records should include observations and data, not merely conclusions. However, documentation expectations should comport with normal clinical documentation practices. Unless elements in the record require explanation, such as a non-morbid diagnosis or indicators of likely greater than 6-month survival, as stated below, no extra or additional record entries should be needed to show hospice benefit eligibility.

The amount and detail of documentation will differ in different situations. Thus a patient with metastatic small cell cancer may be demonstrated to be hospice eligible with less documentation than a chronic lung disease patient. These situations are obvious. Patients with chronic lung disease, long term survival in hospice, or apparent stability can still be eligible for hospice benefits, but sufficient justification for a less than six month prognosis should appear in the record.