Every hospice clinician I’ve worked with leads with compassion. We see the suffering. We witness the decline. And we document the care, hoping it will be enough. But sometimes what feels like “enough” in our hearts isn’t “enough” for a Medicare auditor.
That’s where Local Coverage Determinations come in. LCDs, published by the Medicare Administrative Contractors (MACs), are the guidelines used to establish clinical eligibility for the hospice benefit. Many well-meaning clinicians stumble when applying them — especially in complex or non-linear disease trajectories. If you’ve ever been frustrated by a denial on a patient you knew was appropriate, you’re not alone. Here are the five pitfalls I see most, and how to avoid each one.
What LCDs Are — and Why They Matter
An LCD is essentially Medicare’s roadmap for deciding whether a patient’s prognosis is likely six months or less. Some diagnoses — COPD, CHF, Alzheimer’s — have disease-specific LCDs. Others rely on the General Decline criteria: weight loss, functional decline, increasing dependence. Applied well, these criteria establish eligibility clearly, support the claim with objective findings, and reduce audit risk. The challenge is that even excellent clinicians sometimes write a compelling narrative without ever explicitly tying it back to an LCD benchmark — and that disconnect is where claims fall apart.
The Five Most Common LCD Pitfalls
1. Narrative without evidence
A heartfelt story conveys the situation emotionally, but on its own it won’t hold up on review. Consider a note like this:
This patient is clearly declining and needs hospice. They have severe heart failure and are always tired. They’ve been in and out of the hospital a lot lately. The family is overwhelmed, and they just want comfort care. I believe they have less than six months to live because they look so sick.
It’s sincere — and it doesn’t give an auditor a single measurable finding. Match each narrative claim to a corresponding LCD criterion. Don’t just say “declined” — show how. If the PPS went from 50% to 40%, describe what changed: the patient is now mostly in bed, whereas last certification period they could sit in a chair; self-care has progressed from needing help with 4 of 6 ADLs to 5 of 6 (and for extra credit, name which ADLs changed). If they’re losing weight, describe how they appear — frail, loose-fitting clothes, visible bony prominences, temporal wasting.
2. Skipping General Decline when no disease-specific LCD fits
Not every diagnosis has a defined LCD. Patients with Parkinson’s disease, multi-system failure, or general frailty often don’t fit neatly into a disease-specific bucket — but they may still qualify if the General Decline criteria are thoroughly documented. When in doubt, work the General Decline checklist. Don’t ignore it simply because there’s no disease-specific LCD to lean on.
3. Outdated or static assessments
Initial eligibility isn’t enough. Recertification demands evidence of ongoing decline. If the PPS stays at 50, weight is stable, and no new symptoms have emerged, the chart raises questions. Use comparative data across certification periods — weight trends, new hospitalizations, increasing oxygen needs — and document the trajectory, not just the snapshot.
4. Missing functional scores
Functional status is central to LCD support, yet standardized tools are often left out or applied inconsistently. The Palliative Performance Scale (PPS), the FAST scale for dementia, and NYHA class for heart failure aren’t nice-to-haves — they’re core to LCD alignment. Standardize their use and include the score in every certification narrative.
5. Over-reliance on comorbidities
Advanced age, diabetes, or a prior stroke help paint the picture — but they don’t qualify the patient on their own. Use comorbidities to contextualize decline, not to justify hospice by themselves, and always tie them back to how they accelerate the progression of the primary terminal illness.
Where Real-Time Support Helps
LCDs are dense, and hospice staff are stretched thin. That’s exactly why I built Hospice Intelligence — to put LCD-aligned guidance in front of nurses and physicians in the moment, so the criteria are addressed and updated while the note is still open rather than discovered missing during an appeal. Documentation should reflect the care you give, not become a barrier to it.
Compassion and Compliance Are Not in Tension
Hospice care is about dignity at the end of life. To honor that mission, we also have to speak Medicare’s language. LCDs aren’t bureaucratic hoops — they’re the framework that keeps hospice sustainable and accessible. Avoid these five pitfalls, and your words will match your intentions: patients keep the care they qualify for, and the documentation is more likely to defend it.
If this was helpful, follow along — I post Medicare compliance education every Wednesday. Which of these five do you see most often in your own agency’s charts? Share below; I read every comment.
Want this kind of education in your inbox every week? Subscribe at hospiceintelligence.com.
Brian Haas, DO, FACP, HMDC, CPE — National Medical Director and founder of Hospice Intelligence.