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Hospice documentation guide

End-Stage Liver Disease (Cirrhosis)

ICD-10: K74.x / K72.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.
  • 1End-stage liver disease with Child-Pugh score Class C (≥10 points), OR
  • 2Refractory ascites despite paracentesis, OR
  • 3Hepatic encephalopathy (Grade 3–4 or recurrent), OR
  • 4Spontaneous bacterial peritonitis (history of), OR
  • 5Hepatorenal syndrome, OR
  • 6Hepatic hydrothorax
  • 7Not a transplant candidate OR patient declined transplant
  • 8PPS below 70, dependence in 2+ ADLs

Charting Tips for Audit Defense

  • Document Child-Pugh score components: bilirubin, albumin, PT/INR, ascites, encephalopathy
  • Record frequency and volume of paracenteses
  • Note whether patient is transplant candidate and why not (or why they declined)
  • Track sodium level for hyponatremia (indicator of severity)
  • Document encephalopathy grade and lactulose regimen

Common Documentation Mistakes

Not calculating Child-Pugh score — state the class explicitly
Documenting ascites without noting whether it's refractory
Not addressing transplant candidacy
Missing INR documentation (a Child-Pugh component)

Sample Note Findings (LCD-Aligned)

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

Child-Pugh Class C (score 12): bilirubin 4.2 mg/dL (3 pts), albumin 2.0 g/dL (3 pts), INR 2.8 (3 pts), severe ascites requiring paracentesis (3 pts), Grade 2 encephalopathy (2 pts).
Refractory ascites: 6 paracenteses in past 4 months, most recent 04/18/2026, 5.5L removed. Patient not tolerating further spironolactone dose increase per nephrology.
Not a transplant candidate per hepatology 03/2026 due to ongoing alcohol use history and functional status. Patient declined further evaluation.
Lactulose 30mL TID with target of 2–3 soft bowel movements daily. Encephalopathy Grade 2 (disorientation, asterixis present on exam).

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