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Recertification Narrative Template — Hospice Visit Note Template

The recertification narrative is the document auditors read most carefully. Generic language and copy-forward text are the two most common reasons valid recertifications get denied. This template structures a narrative that connects specific benefit-period evidence to the prognosis.

LCD L34538 / L33393 Quick Check

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Physician or NP authored (not RN alone)

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Face-to-face completed within 30 days (BP3 and beyond)

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Benefit period dates correct — matches claim

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Clinical rationale is specific, not copy-forward

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Any 'improving' documentation addressed/contextualized

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LCD criteria explicitly referenced (FAST stage, EF, SpO₂, etc.)

Check all boxes before filing.

Recertification Header

Patient name / MRN
Primary diagnosis (LCD category)
Benefit period number
Benefit period dates(from: ___ to: ___)
Certifying physician name / NP
Date narrative completed
Face-to-face date (BP3+)(must be within 30 days before period start)
Face-to-face conducted by(hospice physician / NP — NOT the attending unless dual role documented)

Disease Trajectory This Benefit Period

PPS at start of period
PPS at end / recert
PPS change and interpretationdecline of ___ points; significance for prognosis
Weight at start of period (lbs / date)
Weight at end / recert (lbs / date)
Weight change / percentage(___ lbs / ___% over ___ days)
Hospitalizations or ER visits this period(number: ___ dates: ___ reason: ___)
Key clinical events this periodinfections, falls, new symptoms, medication changes

LCD-Specific Clinical Evidence

Dementia:FAST substage: ___ Verbal output: ___ Secondary condition: ___
Cardiac:NYHA class: ___ Most recent EF: ___% (date: ___) Rest symptoms: Y/N
Pulmonary:SpO₂ on RA: ___% MRC scale: ___ ER/hosp count: ___
Cancer:Treatment status: ___ Weight loss %: ___ Disease progression evidence: ___
L33393 (non-specific):Nutritional indicators: ___ ADL dependence: ___ Functional trajectory: ___

ADL Status at Recertification

☐Bathing: [ ] Independent [ ] Needs assist [ ] Total care — change since last cert: ___
☐Dressing: [ ] Independent [ ] Needs assist [ ] Total care — change: ___
☐Toileting: [ ] Independent [ ] Needs assist [ ] Total care — change: ___
☐Transferring: [ ] Independent [ ] Needs assist [ ] Total care — change: ___
☐Feeding: [ ] Independent [ ] Needs assist [ ] Total care — change: ___
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Free template — 8 sections

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What's in the full template (8 sections):

✓Recertification Header
✓Disease Trajectory This Benefit Period
☐LCD-Specific Clinical Evidence
☐ADL Status at Recertification
☐Stability Explanation (if applicable)
☐Prognosis Statement (required — must be specific)
☐Face-to-Face Attestation (BP3 and beyond)
☐Certifying Physician Signature

Other templates

Dementia →Cardiac →Pulmonary →Cancer →General Decline →All templates