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Hospice documentation guide

ALS (Amyotrophic Lateral Sclerosis)

ICD-10: G12.21

LCD L34538 Eligibility Criteria

Part II required for all diagnoses:PPS <70 AND dependence in 2+ ADLs. These apply in addition to diagnosis-specific criteria below.
  • 1ALS with rapid progression (lost ≥1 functional ability in past 12 months)
  • 2Critically impaired breathing (forced vital capacity <30% predicted), OR
  • 3Nutritional compromise requiring PEG or NG tube, OR
  • 4Major ADL dependence in 2+ categories: bathing, dressing, toileting, transferring, ambulation

Charting Tips for Audit Defense

  • Document speech intelligibility: 'less than 25% intelligible to strangers'
  • Record FVC if available with date and source
  • Note whether patient is using BiPAP and hours of use
  • Document rate of progression: what they could do 6 months ago vs now
  • Track weight and dysphagia status

Common Documentation Mistakes

Documenting ALS without showing rate of progression
Not addressing breathing impairment — it's the primary life-limiting factor
Missing functional decline timeline

Sample Note Findings (LCD-Aligned)

These examples show the level of specificity needed to survive ADR review. Generic language will not suffice.

ALS with rapid progression. Comparison to 6 months ago: was ambulatory with cane → now wheelchair-bound; was speaking in full sentences → now <25% intelligible with AAC device.
FVC 22% predicted per pulmonology 03/15/2026. Patient using BiPAP 18–20 hours/day. Declined tracheostomy and vent after family discussion.
Dependent in all ADLs. Requires hoyer lift for transfers. Full assist with bathing, dressing, toileting. Feeding: wife places spoon; patient unable to self-feed due to arm weakness.
Dysphagia: modified texture diet (pureed), thin liquids cleared by SLP. Family trained in Heimlich maneuver.

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