Does this tool determine hospice eligibility?

No. Only the hospice medical director can certify a terminal prognosis of six months or less. This tool is a documentation aid to help you organize the indicators supporting eligibility.

Where do the eligibility indicators come from?

The indicators are drawn from published MAC Local Coverage Determinations (LCDs) for each disease category and from the CMS Medicare Benefit Policy Manual, Chapter 9.

Is my data stored or transmitted?

No. This tool runs entirely in your browser. Your inputs are not sent to a server, logged, or persisted anywhere. Close the tab and everything is gone.

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Hospice Eligibility Checklist

Walk through the Medicare hospice eligibility indicators for your patient’s primary terminal diagnosis and produce a paste-ready documentation summary. Runs entirely in your browser — no login, no data leaves this page.

Documentation aid, not a certification tool

Only the hospice medical director can certify a terminal prognosis. This checklist helps you organize the indicators supporting eligibility — it does not determine eligibility.

Indicators marked

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Optional patient reference (initials, chart # — never leaves this page)

1 · General hospice eligibility

These indicators apply to every hospice admission regardless of diagnosis.

2 · Terminal diagnosis category

Pick the disease grouping that best matches the patient. Indicators map to the corresponding MAC LCD.

3 · Disease-specific indicators

Grounded in Palmetto/CGS/Noridian Heart Disease LCD. Not every indicator is required; more indicators strengthen the documentation.

4 · Documentation summary

Copy or download this block to attach to your narrative note. Nothing here is stored on our servers.

Hospice Eligibility Documentation Checklist
Date: 2026-08-16
Terminal diagnosis category: Heart failure (CHF / advanced cardiac)

General hospice eligibility indicators present:
  [ ] Physician has determined life expectancy ≤ 6 months if disease runs its normal course
  [ ] Patient (or authorized representative) elects hospice benefit and understands the palliative goal
  [ ] Documented decline over recent weeks/months (not a single acute event)
  [ ] Face-to-face encounter is scheduled or completed as required for the benefit period
  [ ] Advance directives, code status, and goals of care documented
  [ ] Primary caregiver identified (or plan of care addresses lack of caregiver)

Disease-specific indicators present (Heart failure (CHF / advanced cardiac)):
  [ ] NYHA Class IV symptoms at rest despite optimal medical therapy
  [ ] EF ≤ 20% (if measured) OR persistent symptoms despite maximal Rx
  [ ] Recurrent symptomatic ventricular arrhythmias resistant to treatment
  [ ] History of cardiac arrest or resuscitation
  [ ] Recurrent syncope of cardiac origin

Notes:
- This checklist is a documentation aid only. Eligibility certification remains the responsibility of the hospice medical director.
- Reference LCD: Palmetto/CGS/Noridian Heart Disease LCD

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Sources

Educational content only. Not a substitute for your organization’s policies, your medical director’s clinical judgment, or current MAC LCDs.