What should be included in the face-to-face evaluation for hospice recertification for a 63-year-old male with a malignant neoplasm of the skin, significant decline in functional and cognitive status, and multiple comorbidities, including asthma, hyperlipidemia, supraventricular tachycardia, gout, and basal cell carcinoma, who is experiencing increased confusion, pain, dyspnea, and decreased nutritional status, and is currently taking oxycodone, gabapentin, Lasix, and Zyprexa?

Enhancing Your Hospice Recertification Face-to-Face Evaluation

Your documentation should explicitly include prognostic indicators demonstrating continued terminal illness with life expectancy ≤6 months, quantifiable evidence of disease progression since the last certification period, and a clear statement linking clinical findings to terminal prognosis—this is the core requirement for LCD compliance. 1

Critical Missing Elements for LCD Compliance

1. Explicit Prognostic Statement

You must include a direct statement about prognosis and life expectancy:

• State clearly: "Based on the clinical findings documented above, this patient's prognosis remains ≤6 months if the disease follows its expected course." 1
• Reference the specific LCD criteria being met (e.g., "Patient meets LCD criteria for malignant neoplasm with metastatic disease and declining functional status") 1

2. Quantifiable Disease Progression Documentation

Your note needs explicit comparison to the prior certification period:

• Document specific measurable changes: "Tumor has increased from [prior measurement] to current size extending from forehead to cheekbone" 1
• PPS decline is excellent—emphasize this: "PPS declined from 60% to 40% over [timeframe], representing significant functional deterioration" 1
• MUAC decline is valuable—make it more prominent: "MUAC decreased 3.2 cm over [timeframe] (from 24.7 to 21.5 cm), indicating progressive nutritional decline despite interventions" 1, 2

3. Refractory Symptom Documentation

Strengthen your symptom burden documentation:

• Pain escalation: "Pain has become increasingly refractory, requiring opioid dose escalation from [prior dose] to oxycodone 15mg q2h PRN, with gabapentin increased to 300mg BID—indicating progressive disease burden" 1
• Dyspnea progression: "Dyspnea has progressed from exertional to occurring at rest, requiring increased albuterol use—consistent with advancing disease" 3
• Delirium/cognitive decline: "New onset confusion and decreased alertness over past week represents terminal delirium, a poor prognostic indicator" 1

4. Comorbidity Impact Statement

Link comorbidities to overall decline:

• "Recent septic shock episode requiring hospitalization demonstrates vulnerability to life-threatening complications and overall disease burden" 1
• "New bilateral lower extremity edema requiring diuretic initiation suggests declining cardiovascular reserve in context of terminal illness" 4

5. Functional Decline Specifics

Expand your functional assessment:

• "Patient previously independent with all ADLs; now requires caregiver assistance with dressing changes and has reduced bathing frequency due to fatigue—representing progressive functional decline" 1
• "Increased sleeping 4-5 hours during day (up from 1-2 hours) indicates declining energy reserve and approaching end of life" 1, 5
• "Requires 24-hour caregiver supervision (daytime and overnight 2000-0600) due to safety concerns from confusion and fatigue" 1

6. Nutritional Decline Documentation

Your nutritional data is strong but needs clearer framing:

• "Progressive anorexia with decreased PO intake, now consuming only small amounts of pudding/snacks and missing meals—despite appetite stimulant (Zyprexa) initiated [date]" 1, 2
• "Serial MUAC measurements demonstrate ongoing cachexia: 24.7 cm → 22.5 cm → 21.5 cm, indicating treatment-refractory nutritional decline" 1, 2

7. Clinical Trajectory Statement

Add a forward-looking prognostic statement:

• "Clinical trajectory demonstrates accelerating decline with multiple concurrent symptoms (pain, dyspnea, confusion, edema, anorexia) emerging or worsening in recent weeks, consistent with terminal phase of illness" 1
• "Despite aggressive symptom management interventions (opioid escalation, diuretics, appetite stimulants), patient continues to decline—indicating refractory disease progression" 1

Specific Documentation Additions

Physical Examination Enhancement

Your exam is adequate but add:

• Vital signs: Include respiratory rate, heart rate, blood pressure, and oxygen saturation if available 1, 3
• Weight if available: "Weight [X] kg, down from [Y] kg on [prior date]" 1
• Edema grading: You noted "3+ bilateral lower extremity pitting edema"—this is excellent, keep it 4

Cognitive Assessment Enhancement

• Consider adding a brief cognitive screening score: "4AT score [X] indicating delirium" or "Oriented to person and place only, not to time or situation" 6
• "Repeating self during visit and difficulty answering questions represents acute cognitive decline from baseline" 1, 6

Symptom Burden Quantification

• Pain: "Pain rated [X/10] at rest, [Y/10] with movement, requiring around-the-clock opioid dosing" 1
• Dyspnea: "Dyspnea occurs with minimal exertion and at rest, limiting activities" 3

Final Attestation Enhancement

Replace your current attestation with:

"I attest that I performed a face-to-face encounter with the above-named patient on [DATE]. Based on my examination and review of the medical record, this patient continues to have a terminal prognosis with life expectancy of ≤6 months if the disease follows its expected course. The clinical findings documented above—including progressive functional decline (PPS 60%→40%), refractory symptom burden requiring escalating interventions, ongoing nutritional decline (MUAC 24.7→21.5 cm), new cognitive impairment, and recent life-threatening complication (septic shock)—support continued hospice eligibility. These findings were reported to the certifying physician [NAME] for determination of continued hospice care eligibility. I confirm that I composed this narrative based on my examination of the patient and review of the medical record." 1

Common Pitfalls to Avoid

• Never assume LCD reviewers understand implied prognosis—state it explicitly 1
• Avoid vague terms like "continues to decline"—use specific measurable changes 1, 2
• Don't document symptoms without linking them to disease progression and terminal prognosis 1
• Failure to compare current status to prior certification period is a common denial reason 7
• Missing the explicit ≤6 month prognosis statement is the most frequent documentation error 1