For healthcare professionals navigating hospice referrals, understanding the Medicare hospice eligibility framework and how to document it effectively are essential to ensuring patients receive timely, appropriate end-of-life care.
This guide outlines how to assess terminal status, apply hospice eligibility criteria in practice, and align hospice documentation of decline with review standards.
For individuals or families seeking guidance on when hospice may be needed, please read our blog on when to call hospice.
Important Takeaways
- Hospice eligibility criteria rely on documented patterns of decline, not diagnosis alone.
- Strong hospice documentation of decline is essential for coverage and recertification.
- PPS score hospice benchmarks and Karnofsky hospice eligibility thresholds support (but do not determine) eligibility.
- Clear, narrative-driven documentation improves clinical and regulatory confidence.
Medicare Hospice Eligibility: The Foundation
Hospice eligibility requires that:
- The patient is enrolled in Medicare Part A
- A physician certifies a prognosis of six months or less if the disease follows its expected course
- The patient elects comfort-focused care over curative treatment
These baseline hospice eligibility criteria are intentionally broad. Patients do not need to meet every guideline listed by the Centers for Medicare & Medicaid Services (CMS), but the clinical record must support the prognosis.
Eligibility can then be established through one of two pathways:
- Part I: Documented decline in clinical status over time (non-disease-specific)
- Part II: Non-disease-specific baseline guidelines combined with disease-specific criteria
Part I: Decline in Clinical Status
Because this pathway requires ongoing assessment, both baseline and follow-up data must be documented. Baseline may be established at admission or drawn from existing records.
The variables below are listed roughly from most to least predictive of poor survival. No fixed number must be met, but fewer high-predictive indicators should be offset by more of the lower-predictive ones.
Disease Progression | Progressive Inanition | Symptoms Unresponsive to Treatment |
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Clinical Signs | Laboratory Values | Functional Decline |
| (Not required, but supportive when available.)
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Performance Scales: PPS and KPS
Two validated tools are used to assess functional status for hospice eligibility criteria.
- A Karnofsky Performance Status (KPS) score below 70% is the threshold for hospice eligibility under Part II baseline criteria.
- The Palliative Performance Scale (PPS) assesses ambulation, activity level, evidence of disease, self-care, oral intake, and level of consciousness. The hospice-qualifying threshold is likewise below 70%.
PPS Score in Hospice Eligibility | Karnofsky Performance Status |
The PPS score (Palliative Performance Scale) helps quantify functional decline:
While the PPS score hospice threshold supports eligibility, it must be paired with narrative and clinical context. | The Karnofsky Performance Status (KPS) offers a parallel framework:
As with PPS, KPS strengthens, but does not replace, comprehensive documentation. |
Part II: Non-Disease-Specific Baseline Guidelines
Both of the following criteria should be met:
- KPS or PPS below 70%
- Dependence on assistance with two or more ADLs (feeding, ambulation, continence, transfer, bathing, or dressing)
These baseline criteria must be used in conjunction with the applicable disease-specific guidelines. They do not independently qualify a patient for hospice coverage.
Note: HIV, stroke, and coma require a lower KPS/PPS score to qualify.
Disease-Specific Criteria
Disease-specific guidelines are used alongside the Part II baseline criteria. Two key examples include:
Cancer
- Distant metastases at presentation, or
- Progression to metastatic disease with continued decline despite therapy, or the patient declining to receive further disease-directed therapy
- Certain cancers with inherently poor prognoses (small cell lung, brain, pancreatic) may qualify without meeting all other criteria
Dementia (Alzheimer’s and Related Disorders)
- FAST score 7+
- Unable to ambulate, dress, or bathe without assistance; urinary and fecal incontinence; no consistently meaningful verbal communication
- Plus one of the following within the past 12 months: aspiration pneumonia, upper UTI, pyelonephritis, septicemia, multiple stage 3–4 decubitus ulcers, recurrent fever after antibiotics, or inability to maintain adequate fluid/caloric intake with ≥10% weight loss in six months or albumin <2.5 g/dL
Comorbidities That May Support Eligibility
While not the primary hospice diagnosis, comorbid conditions whose severity likely contributes to a ≤6-month prognosis should be factored into eligibility determinations. These include:
- Chronic obstructive pulmonary disease (COPD)
- Congestive heart failure (CHF)
- Ischemic heart disease
- Diabetes mellitus (DM)
- Neurologic disease (Parkinson’s, ALS, MS, CVA)
- Renal failure
- Liver disease
- Neoplasia
- HIV/AIDS
- Dementia
- Refractory autoimmune disease (lupus or rheumatoid arthritis [RA])
Hospice Documentation of Decline: What Reviewers Expect
Clear, thorough documentation is the backbone of hospice eligibility. The most effective hospice documentation answers 4 questions:
- What has changed?
- Over what timeframe?
- Despite what interventions?
- With what functional impact?
Records should “paint a picture” that clearly justifies why the patient is appropriate for hospice care and at what level (routine home, continuous home, inpatient respite, or general inpatient).
When in doubt, err on the side of detail. The reviewer should be able to read the record and, without inference, understand why this patient is appropriate for hospice at this time.
Documentation Best Practices
- Record observations and data, not just conclusions. Specific, dated clinical findings carry more weight than summary statements.
- Establish baseline, then show change. Documentation of decline requires a reference point. Both must appear in the record.
- Address inconsistencies directly. If the record contains findings that could suggest a prognosis longer than six months (e.g., recovered ADLs, prolonged hospice stay, low immediate-mortality diagnosis), those should be explicitly explained or refuted elsewhere in the documentation.
- Match detail to complexity. A patient with metastatic small cell lung cancer requires less documentation scaffolding than a patient with chronic lung disease or apparent clinical stability. The latter requires more explicit justification.
- Include supporting events. Recent hospitalizations, changes in ADL dependence, and (when billing for a prior period) known date of death all strengthen the record.
- Documentation may span beyond the billing period. Records from adjacent time periods may be submitted in support of a coverage determination.
“Painting the Picture” of a Terminal Patient for Hospice Documentation of Decline
Weight Loss | Loss of Appetite |
The patient cannot be weighed on the scales due to bedbound status. MAC is 18cm. During the interview with the daughter, who has been caring for the patient over the past year, she said that her mother has lost weight in the past 3 months, but was unable to state how much. The daughter states that her mother previously wore clothing in a women’s size 16, but over the past few months, she has had to gradually buy her mother new clothing due to her old clothes “falling off of her.” The patient is now able to wear a women’s size 10. | The patient has been eating 4 to 6 child-sized meals per day but has consumed only about 25% of each meal. This consists of:
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Decline in Functional Status | Sleeping |
The patient requires assistance with bathing at the sink and dressing his lower body. He now uses a walker for all ambulation inside and outside of his room. The patient was completely independent with all ADLs, driving, and working every day until 3 months ago when he was diagnosed. | The nurse’s aide reports that the patient sleeps 8–10 hours at night, then takes a 3–4-hour nap during the day. When the patient is in a chair for more than an hour, she frequently dozes off. This is a change from just 2 months ago, when the patient wasn’t sleeping at night; she experienced agitation in the evening, and slept for only a few hours during the day. |
When Patients Stabilize
Patients who stabilize or improve during hospice care do not automatically lose eligibility.
If clinical judgment supports that the patient has a reasonable expectation of continued decline with a life expectancy of less than six months, they remain eligible. However, if improvement is sustained and the patient no longer meets the prognosis threshold (and that improvement can reasonably be expected to continue outside hospice), discharge from hospice is appropriate.
Recognize Eligibility? Take the Next Step
When a patient’s trajectory suggests hospice eligibility, early collaboration can support better outcomes. If you’re assessing a patient who may meet hospice eligibility criteria, our team at The Connecticut Hospice is available to review clinical indicators, support documentation, and guide next steps.
