Hospice eligibility guidelines for clinicians

In this section

What is the legal standard for hospice eligibility?

The standard is in regulation, not in the guidelines. Under 42 CFR 418.20 a person must be entitled to Medicare Part A and be certified as terminally ill under 42 CFR 418.22. Terminally ill means a medical prognosis of a life expectancy of six months or less if the illness runs its normal course (42 CFR 418.3). The certification rests on the physician's clinical judgment and must be supported by clinical information and a brief physician narrative in the record.

The LCD guidelines exist to help clinicians and reviewers recognize when that prognosis is reasonable. Meeting the indicators is generally accepted as supporting the prognosis. Not meeting them does not by itself make a patient ineligible.

How to use the guidelines

1. Step 1

   Start with the trajectory

   Look at the last three to six months. Is there documented decline in function, nutrition or disease status that is not explained by a reversible cause?

2. Step 2

   Check the functional baseline

   The guidelines use a Palliative Performance Scale (PPS) or Karnofsky Performance Status (KPS) below 70% and dependence in at least two activities of daily living as a baseline for most diagnoses. Some diagnoses set a lower score. See the diagnosis page.

3. Step 3

   Apply the diagnosis-specific indicators

   Each diagnosis page has an indicator table. Note which indicators are met, which are not, and which could not be measured.

4. Step 4

   Add comorbidities and other factors

   Comorbid conditions and their severity count toward prognosis. So does a patient's informed decision to decline further disease-directed treatment.

5. Step 5

   Use judgment and document it

   If the overall picture supports a prognosis of six months or less, say why in specific, measurable terms. If you are unsure, call and talk it through.

General decline indicators

These apply to any terminal diagnosis. They carry more weight when they are documented over time, with dates and values, and are not due to a reversible cause.

Summarized for reference. For exact wording and any thresholds, see the LCD.

What if the patient does not meet the guidelines?

Patients who do not meet the guidelines may still be eligible. The LCD guidance itself says so. Some patients decline quickly without ever reaching a listed laboratory value. Some have several moderate conditions that together are terminal. Some have a test that was never done, and ordering it would not change care.

What matters is that the record explains the prognosis. Useful documentation includes the rate of decline, comorbidities and their severity, the patient's decision about further treatment, and any clinical findings that make the expected course shorter than the diagnosis alone would suggest. The certifying physician's narrative should be specific to the patient and should not restate the checklist.

The reverse is also true. A patient who meets the indicators but then stabilizes or improves may no longer have a six-month prognosis. Hospice physicians reassess this at every recertification. A patient who is discharged for extended prognosis can be referred again if decline resumes.

Who makes the decision?

For the first benefit period, the hospice medical director or hospice physician and the patient's attending physician, if there is one, both certify. A referral is a request for evaluation. It is not a commitment by you or the patient. See the physician guide for certification, the attending role and the face-to-face rule, and levels of care criteria for general inpatient, continuous home care and respite.

If a patient has a heavy symptom burden but is unlikely to meet hospice criteria yet, consider palliative care.

Common questions