LCD L34538 in plain English: what every hospice nurse must know

Nobody handed you a copy of LCD L34538 when you started. Most nurses have absorbed pieces of it over years — from what their DON told them, from ADRs that came back denied, from a colleague who got burned on a chart that seemed bulletproof. The problem with learning it that way is that you end up knowing the parts that bit someone near you, but not necessarily the parts that are quietly undermining your own charts.

LCD L34538 is the Medicare document that defines the clinical criteria for hospice eligibility across the most common diagnoses. Your MAC — the Medicare Administrative Contractor that reviews your claims — uses it to decide whether your documentation supports the claim. If it doesn't map to the LCD, the claim can be denied. If you can't demonstrate the mapping during an ADR, you return the money.

The baseline that catches everyone first

Before any diagnosis-specific criteria matter, two things have to be true for every single patient, and both have to be in the chart — not implied, not clinically obvious, documented:

PPS below 70. And dependence in at least two ADLs.

I've seen charts where the clinical picture was unambiguous. End-stage heart failure, NYHA Class IV, EF of 15%, the patient barely functional. And the chart said "PPS 70, ADLs intact with supervision." That's a denial. The auditor isn't evaluating the patient — they're evaluating the chart.

Document PPS at every visit. Document each ADL by name — bathing, dressing, toileting, transferring, feeding — not "dependent in ADLs." By name, with the level of dependence specified.

Pulmonary disease: the AND vs. OR confusion

The pulmonary criteria have two parts. Criterion 1 requires either dyspnea at rest or two or more ER visits/hospitalizations in the prior 12 months for COPD exacerbation. That's an OR — either one satisfies criterion 1 on its own.

Criterion 2 is separate and always required: SpO2 ≤ 88% on room air, pCO2 ≥ 50 mmHg, or documented oxygen dependency. You need criterion 2 no matter how clear criterion 1 is.

The mistake I see constantly is nurses thinking they need both dyspnea and hospitalizations. They don't. But a patient with severe dyspnea and SpO2 of 93% on room air doesn't qualify — criterion 2 isn't met.

Dementia: the substage that ends claims

The LCD requires FAST Stage 7A or beyond. Not FAST 7 — Stage 7A. The letter matters.

FAST Stage 7 has six substages (7A through 7F). Eligibility starts at 7A, which is speech limited to six or fewer intelligible words per day. A patient at FAST 6E — even profoundly impaired — does not qualify under the dementia criteria. Auditors know the substages. Your chart needs to document them.

Every dementia patient's chart should have: the specific FAST substage, the verbal output observed during that visit ("patient said 'no' twice in a 45-minute interaction, all other vocalizations non-intelligible"), and the secondary condition. The secondary condition is required — aspiration, pressure injury, recurrent UTI, significant weight loss, or recurrent fever. Many agencies miss it entirely.

Cardiac: the number most charts get wrong

Heart failure requires either EF ≤ 20% — very low — or documented symptoms at rest despite maximal therapy, or treatment-refractory arrhythmia. If your patient's most recent echo shows EF 35% and the chart has no rest symptoms documented, the cardiac LCD criteria aren't met.

That patient may still qualify under L33393 (the non-disease specific LCD) based on functional decline and nutritional status — but not under L34538 cardiac. Know which LCD you're documenting under. Document to that one specifically.

The thing that actually survives an ADR

A note that says "patient is debilitated and declining" is not audit-defensible. A note that says "PPS 40, dependent in bathing, dressing, and toileting; FAST 7B with no intelligible words this visit; 12% weight loss over 5 months; secondary aspiration pneumonia documented last month" maps directly to the LCD and survives review.

The standard isn't complicated. It's specific, observable findings documented in the chart at every visit, in language that connects back to the criteria your MAC is checking. Write the chart for the auditor who hasn't met the patient — because that's who's reviewing it.