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Hospice documentation guide

End-Stage Cardiac Disease (Heart Failure)

ICD-10: I50.x

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.
  • 1NYHA Class IV heart failure (symptoms at rest or with minimal exertion)
  • 2Ejection fraction ≤20%, OR significant valvular disease not amenable to repair/replacement
  • 3Optimally treated with maximal tolerated diuretics and vasodilators
  • 4May also qualify with treatment-refractory arrhythmia
  • 5PPS below 70
  • 6Dependence in 2+ ADLs

Charting Tips for Audit Defense

  • Document NYHA Class IV explicitly with functional description: 'symptoms at rest'
  • Record ejection fraction with source: 'EF 15% per echo 02/2026 per Dr. Smith'
  • Note diuretic regimen and dose: 'Lasix 80mg BID at maximum tolerated dose'
  • Document hospitalizations for CHF exacerbation: frequency, dates
  • Track dyspnea at rest, orthopnea, lower extremity edema at every visit

Common Documentation Mistakes

Documenting EF without the date or ordering physician
NYHA Class III instead of IV — Class III is 'symptoms with less than ordinary activity'; IV is 'symptoms at rest'
Not documenting that therapy is maximal — auditors look for this
Missing the PPS assessment
Not linking fluid restriction, low-sodium diet, and activity restrictions to the care plan

Sample Note Findings (LCD-Aligned)

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

NYHA Class IV CHF: patient dyspneic at rest, unable to perform any activity without distress. Cannot speak full sentences without pausing to breathe.
EF 15% per echocardiogram 02/14/2026, Dr. Rivera. No surgical intervention planned. ICD declined by patient.
On maximum tolerated diuresis: Lasix 80mg BID, Aldactone 25mg daily, Metolazone 2.5mg PRN. Cardiology agrees no further upward titration tolerable without renal compromise.
Lower extremity edema 3+ pitting to knee bilaterally. Weight up 4 lbs since last visit despite diuretics.
PPS 30: confined to bed or chair >50% of day, unable to do any work, requiring significant assistance with self-care, intake reduced.

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