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Printed Date: 9/22/2015
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 Medicare Administrative Contractor (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.
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Last Updated: 10/19/2020