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Hospice documentation guide

Dementia (Alzheimer's and Related Disorders)

ICD-10: G30.x / G31.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.
  • 1FAST Stage 7A or above (fewer than 6 intelligible words per day; numeric encoding ≥7.1)
  • 2Dependence in 2+ ADLs (bathing, dressing, toileting, transferring, feeding)
  • 3PPS below 70
  • 4At least one secondary condition: aspiration pneumonia, septicemia, pyelonephritis, pressure ulcer Stage 3–4, recurrent fever, or ≥10% weight loss in 6 months

Charting Tips for Audit Defense

  • Document FAST stage explicitly at every visit — never just 'advanced dementia'
  • Count and name the fewer than 6 words patient can say; quote them
  • List each ADL dependency by name: bathing, dressing, toileting, transferring, feeding
  • Record weight at every visit; track percentage lost from baseline
  • Name the secondary condition with dates: 'aspiration pneumonia per chest X-ray 04/12/2026'

Common Documentation Mistakes

Documenting FAST 7 instead of 7A — plain 7 is NOT sufficient; must be 7A or higher (≥7.1)
Writing 'dependent in ADLs' without naming the specific activities
Omitting the secondary condition — it's required for dementia, not optional
Copy-forward notes that don't show progression between visits
Documenting weight only at admission, not serially

Sample Note Findings (LCD-Aligned)

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

Patient is at FAST Stage 7A — speech is limited to fewer than 6 recognizable words ('Mama,' 'No,' occasionally 'Stop'). FAST 7A confirmed 05/01/2026.
Patient is dependent in all 5 ADLs: bathing (requires full assist), dressing (requires full assist), toileting (incontinent, requires full assist with hygiene), transferring (requires 2-person assist), feeding (requires full assist with pureed diet via hand-over-hand cueing).
Weight 102 lbs today vs 115 lbs on 11/15/2025 — loss of 13 lbs (11.3%) over 6 months despite appetite stimulant trial. Consistent with terminal dementia trajectory.
PPS 30: mainly in bed, unable to do any work, completely unable to perform self-care, intake minimal, drowsy or confused.
Secondary: aspiration pneumonia, treated with oral antibiotics 04/03/2026 per attending Dr. Chen. Recurrent aspiration events per caregiver and family report.

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