Medical Criteria for Hospice Eligibility

Medicare has established guidelines for hospice admissions for most major terminal illnesses. These guidelines are not necessarily accurate in predicting death within six months. However, patients not meeting criteria may not be accepted to a hospice program because Medicare has refused payment for patients not meeting these criteria.

Careful documentation of the medicare hospice criteria as pertaining to that patient is a convenient way to demonstrate the severity of the illness for patients, family and for colleagues as you all work together to develop appropriate goals of care.

Writing a note in the patient’s chart (either inpatient or outpatient) that documents the eligibility for hospice care based on the CMS guidelines can assist the hospice in making a prompt determination of eligibility and would help if there was every a regulatory question of a patients eligibility.

For patients who have a longer than expected survival, reevaluation at time of re-certification will document that the patient is still eligible for home hospice care. In rare situations were patients have unanticipated recovery, they may be discharged from hospice but readmitted later without penalty, if there is decline in health status.

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