Hospice Recertification Documentation for Advanced COPD
To recertify hospice eligibility for a patient with advanced COPD, you must document that both primary criteria (severe chronic lung disease with disabling dyspnea AND disease progression) continue to be met, along with supporting evidence from hypoxemia/hypercapnia, weight loss, and functional decline. 1
Required Primary Documentation (Both Must Be Present)
Criterion 1: Severe Chronic Lung Disease
Document both of the following:
Disabling dyspnea at rest that is poorly or unresponsive to bronchodilators, resulting in decreased functional capacity such as bed-to-chair existence, with associated fatigue and cough 1
- While FEV1 <30% predicted (post-bronchodilator) provides objective evidence, you do not need to obtain spirometry if clinical assessment clearly demonstrates disabling dyspnea 1
Progressive disease course evidenced by increasing emergency department visits, hospitalizations for pulmonary infections/respiratory failure, or increasing physician home visits since the last certification period 1
- Serial FEV1 decline >40 mL/year is objective evidence but is not required 1
Criterion 2: Gas Exchange Abnormality
Document at least one of the following (values may be obtained from hospital records within the past 3 months):
- Hypoxemia at rest: PaO2 ≤55 mmHg on room air, OR oxygen saturation ≤88% on supplemental oxygen 1
- Hypercapnia: PaCO2 ≥50 mmHg 1
Supporting Documentation (Strengthens Recertification)
While not absolutely required, document these when present as they provide additional evidence of terminal prognosis:
- Right heart failure (cor pulmonale) secondary to pulmonary disease—not from left heart disease or valvular pathology 1
- Unintentional weight loss >10% of body weight over the preceding 6 months 1, 2
- Resting tachycardia >100 beats/minute 1
Critical Clinical Context for Recertification
Address the prognostic uncertainty directly in your documentation. The American Thoracic Society acknowledges that predicting 6-month mortality in COPD is inherently difficult, and Medicare will continue coverage beyond 6 months if patients still meet enrollment criteria 3. You are not guaranteeing death within 6 months—you are certifying that the prognosis is more likely than not less than 6 months if the disease runs its natural course 3.
Common Pitfalls to Avoid
- Do not delay recertification waiting for absolute certainty of 6-month prognosis, as the COPD trajectory is unpredictable with sudden fatal exacerbations possible even after periods of relative stability 1, 3, 2
- Do not require new spirometry for recertification—clinical assessment of disabling dyspnea and functional decline is sufficient 1
- Do not overlook depression and anxiety, which are common in advanced COPD and should be documented and treated as part of comprehensive symptom management 3, 2
Additional Documentation Elements
Functional Status and Healthcare Utilization
Document the patient's continued decline through:
- Frequency of exacerbations requiring treatment since last certification 3, 2
- Emergency department visits or hospitalizations for respiratory complications 1, 3
- Progressive functional deterioration in activities of daily living 3, 2
Symptom Burden Assessment
Document ongoing symptoms despite optimal therapy:
- Dyspnea severity and response to current management 3, 2
- Pain, anxiety, depression, fatigue, poor nutrition, cough, insomnia 3
- Impact on quality of life and functional capacity 3
Advance Care Planning Confirmation
Document that:
- DNR/DNI status is confirmed and current 3
- Patient/family understands hospice provides comfort care only 3, 4
- Preferences for management of future exacerbations have been discussed 3, 2
Joint Certification Requirement
Both the treating physician and hospice medical director must jointly certify that the patient's prognosis remains terminal for recertification 2. Your documentation should provide clear evidence that supports this determination based on continued meeting of the above criteria.