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Pulmonary Disease (COPD / ILD / Emphysema) — Hospice Visit Note Template

The two most common audit failures for pulmonary patients: (1) documenting dyspnea but not documenting hypoxemia, and (2) confusing the AND/OR in criterion 1. This template keeps both straight.

LCD L34538 Quick Check

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Criterion 1A OR 1B met:

1A = dyspnea at rest | 1B = ≥ 2 ER/hospitalizations in past 12 mo

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Criterion 2 met (REQUIRED regardless):

SpO₂ ≤ 88% RA | pCO₂ ≥ 50 mmHg | documented O₂ dependency

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PPS ≤ 70%

Most end-stage pulmonary: PPS 40–50

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Dependent in ≥ 2 ADLs (documented by name)

Check all boxes before filing.

Visit Information

Date

Visit time / duration

Patient MRN

Benefit period

Vital Signs

Temp

SpO₂ on room air(___% (document this FIRST before supplemental O₂))

SpO₂ on supplemental O₂(___% on ___ L/min via ___)

O₂ used continuously at home(Y / N — L/min: ___ hours/day: ___)

Respiratory Assessment — LCD Criterion 1

Dyspnea at rest— Dyspnea at rest alone satisfies Criterion 1 — document this clearly if present

☐ Present (Criterion 1A met)☐ On minimal exertion☐ On moderate exertion☐ Only on exertion

MRC Dyspnea Scale

☐ 0 — only strenuous exercise☐ 1 — hurrying / hills☐ 2 — slower pace / stops on level☐ 3 — stops after 100 meters☐ 4 — too breathless to leave home

ER visits for COPD/pulmonary in past 12 months(Number: ___ Dates: ___ (≥ 2 satisfies Criterion 1B))

Hospitalizations for COPD/pulmonary in past 12 months(Number: ___ Dates: ___ (combined with ER visits for Criterion 1B))

Hypoxemia / O₂ Dependency — LCD Criterion 2 (REQUIRED)

SpO₂ ≤ 88% on room air(Y / N — value: ___% (if not safe to obtain on RA, document why and attest to O₂ dependency))

Most recent ABG — pCO₂(mmHg dated ___ (≥ 50 mmHg satisfies C2))

Most recent PFT — FEV1(___% predicted dated ___ (FEV1 ≤ 30% supports but not required))

Clinician attestation of O₂ dependency(If SpO₂ cannot safely be obtained on RA — note here)

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Free template — 9 sections

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What's in the full template (9 sections):

✓Visit Information

✓Vital Signs

☐Respiratory Assessment — LCD Criterion 1

☐Hypoxemia / O₂ Dependency — LCD Criterion 2 (REQUIRED)

☐Respiratory Signs

☐Palliative Performance Scale

☐ADL Status

☐Medications & Exacerbation History

☐Comfort & Plan

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