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General Decline / Failure to Thrive (Non-Disease Specific) — Hospice Visit Note Template

LCD L33393 applies when no single diagnosis dominates the terminal picture — multi-morbid patients, advanced frailty, failure to thrive. The case is built from a combination of functional, nutritional, and symptom burden indicators. You typically need multiple.

LCD L33393 Quick Check

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Nutritional impairment (≥ 1):

BMI ≤ 22 | Weight loss ≥ 10% in 6 mo | Albumin ≤ 2.5 | Dysphagia

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Functional decline (≥ 1):

PPS ≤ 50% | Dependent in ≥ 3 ADLs

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Symptom / trajectory indicators:

Recurrent infection | ≥ 2 ER/hospital visits | Declining treatment | Intractable symptoms

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Multiple indicators documented — not just one

Check all boxes before filing.

Visit Information

Date

Visit time / duration

Patient MRN

Primary diagnoses (list all contributing)

Benefit period

Vital Signs

Temp

SpO₂

Nutritional Status — L33393 Criteria

Weight today(lbs)

Weight 6 months ago (or at admission)(lbs on ___)

Weight change / percentage(lbs / % over ___ days)

BMI (if calculable)(BMI ≤ 22 is an L33393 indicator)

Oral intake

☐ Normal☐ Reduced (~75%)☐ Markedly reduced (~50%)☐ Minimal (~25%)☐ Near zero

Dysphagia(Y / N — diet texture: ___, describe difficulty)

Albumin (if available)(g/dL dated ___ — ≤ 2.5 is an L33393 indicator)

Pre-albumin (if available)

Supplement / tube feeding(Y / N — type, patient response)

Functional Status — L33393 Criteria

PPS Score— PPS ≤ 50 is an L33393 indicator — narrative required

☐ 10☐ 20☐ 30☐ 40☐ 50

Ambulation / activity level

Self-care capacity

☐Bathing: [ ] Needs assist [ ] Total care — ___ person assist

☐Dressing: [ ] Needs assist [ ] Total care

☐Toileting: [ ] Needs assist [ ] Total care

☐Transferring: [ ] Needs assist [ ] Total care — ___ person assist

☐Feeding: [ ] Needs assist [ ] Total care

☐Continence: [ ] Urinary incontinent [ ] Bowel incontinent

Time in bed per day(___ % of day)

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Free template — 7 sections

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What's in the full template (7 sections):

✓Visit Information

✓Vital Signs

☐Nutritional Status — L33393 Criteria

☐Functional Status — L33393 Criteria

☐Symptom Burden & Disease Trajectory — L33393 Criteria

☐Multi-System Decline Indicators

☐Goals of Care & Plan

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