How to Document a Defensible Terminal Prognosis That Survives MAC Review

Below is a concise, structured guide you can adapt into policy, training, or templates to strengthen terminal prognosis documentation for MAC review.

1. Core Goal of the Narrative

Every certification/recertification narrative must clearly answer:

1. Why hospice? (Why a terminal prognosis exists.)
2. Why now? (What changed or is present that makes the prognosis six months or less at this time.)

The narrative must:

• Support a prognosis of six months or less if the illness runs its normal course.
• Be traceable and understandable to a reviewer unfamiliar with hospice and with your EMR.

2. Think Like a MAC Reviewer

MAC reviewers often:

• Are not hospice clinicians and may never have seen an end-of-life patient.
• Only know the patient through what is explicitly documented.

Expect scrutiny when:

• Length of stay is long (e.g., > 90 days, above national median).
• Vitals appear stable or “normal.”
• Principal diagnosis has a longer typical prognosis (CHF, COPD, dementia, debility, etc.).
• There is apparent stability or improvement during a benefit period.
• There is no comparative data between certification periods.
• Narratives are generic and could apply to any patient.

Your documentation must make it easy for a reviewer to see:

• The terminal trajectory over time.
• The specific evidence that supports a six‑month prognosis.

3. Assemble Required Documentation

Per 42 CFR 418.54, the comprehensive assessment must be in the record and must:

• Identify the patient’s need for hospice care and services.
• Address physical, psychosocial, emotional, and spiritual needs related to palliation and management of the terminal illness and related conditions.

For each certification/recertification, ensure the record includes:

1. Comprehensive assessment (initial and updated):

• Physical exam findings.
• Functional status and ADLs.
• Psychosocial, emotional, and spiritual needs.

1. Supporting clinical data, such as:

• Hospital records, ED visits, specialist notes.
• Facility records (SNF/ALF), therapy notes.
• Diagnostic and lab reports.

1. Level of care documentation:

• Date, time, and reason for any level-of-care change (routine, GIP, respite, continuous care).
• Clinical justification for each level of care.

1. Face-to-face encounter documentation (3rd benefit period and beyond):

• Date of encounter within required timeframe.
• Clinical findings from the encounter.
• Required attestation statement.
• Provider signature and credentials.

4. Constructing a Defensible Narrative

4.1 Start With the Trigger: “Why Hospice, Why Now?”

Clearly state what prompted hospice consideration or recertification:

• Recent hospitalization(s) or ED visits.
• Acute change in condition.
• Symptom exacerbation despite treatment.
• Failure to respond to optimal disease management.
• Comorbidities accelerating decline.

Example – Initial Certification:

“Following the third hospitalization in two months for acute respiratory decompensation despite optimal COPD management (maximized inhaler regimen, home oxygen, and pulmonary rehab), the patient demonstrates progressive decline consistent with end-stage COPD, including increasing dyspnea at rest, unintentional weight loss of 12% over 6 months, and reduced functional capacity from independent ambulation to requiring assistance with all transfers.”

4.2 Principal Diagnosis and Related Conditions

The principal diagnosis must be the condition most contributory to the terminal prognosis, not just the most prominent on the problem list.

Document:

• Principal diagnosis driving the six‑month prognosis.
• Comorbid conditions that affect prognosis.
• Secondary conditions that accelerate decline.
• How multiple conditions interact to impact the terminal trajectory.

Example:

“Principal diagnosis: End-stage systolic heart failure (EF 15–20%). Prognosis is further limited by comorbid CKD stage IV, insulin-dependent diabetes with peripheral neuropathy, and chronic atrial fibrillation. The combination of advanced heart failure and renal dysfunction has led to progressive fluid overload, limited ability to further titrate diuretics, and increasing frailty.”

4.3 Use Specific, Measurable Clinical Findings

Avoid vague statements like “patient is declining” or “remains appropriate for hospice.” Instead, document objective, comparative data:

Include, when applicable:

• Weight changes with dates and percentages.
• PPS or Karnofsky scores over time.
• Functional changes:
• Ambulatory → walker → wheelchair → bed-to-chair → bedbound.
• Changes in ADL dependence (bathing, dressing, toileting, feeding, transfers).
• Respiratory status:
• Vital capacity or FEV1 when available.
• O2 requirements (L/min, device type).
• Dyspnea at rest vs exertion.
• Nutrition and intake:
• Caloric intake estimates (e.g., < 50% of meals).
• Documented anorexia, dysphagia, aspiration events.
• Sleep and cognition:
• Hours of sleep per 24 hours.
• Daytime somnolence, confusion, agitation, delirium.
• Wounds:
• Location, stage, measurements, drainage, infection.
• Progression or non-healing despite treatment.
• Laboratory trends:
• Worsening renal function, liver function, tumor markers, albumin, etc.

Example – Comparative Recertification Narrative:

“End-stage CHF progression since last recertification 60 days ago, evidenced by increased diuretic requirements (Lasix increased from 40 mg BID to 80 mg BID), progressive orthopnea now requiring 3 pillows vs 1 pillow previously, and decreased activity tolerance with shortness of breath on minimal exertion (now dyspneic walking 5–10 feet vs 20–30 feet at last certification). Patient’s PPS has declined from 50% to 40%. He now spends > 18 hours/day in bed or recliner vs ~12 hours/day 60 days ago and requires assistance with all ADLs, whereas he previously required assistance with bathing and dressing only.”

4.4 Show Decline Over Time (Comparative Data)

Each recertification must:

• Compare current status to prior certification.
• Show measurable change (even if subtle) or explain why prognosis remains terminal despite apparent stability.

Use explicit comparative language:

• “Since last certification on [date]…”
• “Compared to initial admission on [date]…”
• “Over the past 60/90 days…”

Example – Dementia Recertification:

“Since last recertification 90 days ago, patient with advanced Alzheimer’s dementia has declined from PPS 40% to 30%. She is now nonverbal except for occasional single words, whereas previously she could form short phrases. She requires hand-over-hand assistance for all feeding and consumes approximately 25–30% of offered meals vs 50–60% previously. She has lost 8 lbs (7% of body weight) over 3 months despite staff assistance and oral supplements. She is now incontinent of bowel and bladder continuously, whereas previously she had intermittent continence.”

4.5 Document “Despite Optimal Management”

MAC reviewers expect to see that decline is occurring despite appropriate, optimal disease management, not due to lack of care.

Include:

• Current medication regimen and adherence.
• Relevant procedures or interventions already attempted.
• Specialist involvement (cardiology, pulmonology, oncology, etc.).
• Reasons why further curative or aggressive treatment is not appropriate, not effective, or declined.

Example:

“Despite optimal COPD management including triple inhaler therapy, continuous 3 L/min nasal cannula oxygen, and prior pulmonary rehab, the patient has experienced two ED visits and one hospitalization in the last 60 days for acute exacerbations. Pulmonology notes from [date] indicate no further disease-modifying options and recommend focus on comfort and symptom control.”

4.6 Address Apparent Stability or Improvement

If the patient appears stable or has improved in some areas:

• Acknowledge the improvement directly.
• Clarify why the overall prognosis remains six months or less.
• Emphasize underlying irreversible disease and continued high risk.

Example:

“Since last recertification, patient’s lower extremity edema has improved with increased diuretic dosing; however, this reflects progression of end-stage CHF with limited remaining reserve. He remains NYHA Class IV with dyspnea at rest, PPS 40%, and requires assistance with all ADLs. He has had two near-syncope episodes and continues to decline ICD replacement and hospitalization, maintaining a comfort-focused plan of care. These factors support a continued prognosis of six months or less despite transient symptom improvement.”

5. Avoid Common Documentation Errors

5.1 Copy-Paste Across Benefit Periods

Do not reuse identical or near-identical narratives.

Each recertification must:

• Reflect the current clinical picture.
• Show change over time with dates and measurements.

Fix: Use a structured comparison: “At last recertification on [date]… Currently on [date]…”

5.2 Generic, Non-Individualized Language

Avoid:

• “Patient is appropriate for hospice.”
• “Patient continues to decline.”
• “Patient remains terminal.”

Fix: Replace with patient-specific details:

• Individual symptoms, functional status, psychosocial context.
• Concrete measurements and examples.

5.3 Missing “Despite Optimal Management” Context

MAC reviewers may question eligibility if decline could be due to undertreatment.

Fix: Explicitly state:

• What has been tried.
• Why further disease-directed treatment is not appropriate or effective.

5.4 Not Addressing Improvements or Plateaus

Ignoring improvements invites denials.

Fix:

• Acknowledge improvements.
• Explain why they do not alter the terminal trajectory.
• Emphasize ongoing irreversible decline and risk.

5.5 Incomplete Face-to-Face Documentation

For 3rd benefit period and beyond, ensure:

• Face-to-face encounter occurred within the required timeframe.
• Documentation includes:
• Date of encounter.
• Clinical findings supporting terminal prognosis.
• Attestation statement that the encounter was for hospice eligibility.
• Provider signature and credentials.

6. Building a Defensible, Repeatable Process

Hospices that consistently pass MAC review typically have:

1. Systematic Pre-Billing Review

• Review every record for terminal prognosis support before claim submission.
• Verify presence and quality of narratives, comparative data, and required signatures.

1. Standardized Narrative Structure

Use a consistent template for each certification/recertification, such as:

• Trigger for hospice / “why now.”
• Principal diagnosis and related conditions.
• Objective clinical findings (with dates and measurements).
• Comparative decline since last certification.
• “Despite optimal management” statement.
• Explanation of any stability/improvement.
• Face-to-face summary (when applicable).

1. Proactive Stability Management

• Train clinicians to document stability within a terminal context.
• Include risk factors, irreversible pathology, and prior decline.

1. Complete Record Assembly

• Ensure all outside records (hospitals, specialists, facilities) are obtained and filed.
• Maintain clear timelines of events (admissions, hospitalizations, LOC changes).

1. Technology-Enabled Review

• Use tools that can:
• Flag weak or missing decline narratives.
• Identify contradictions (e.g., high PPS but narrative of bedbound status).
• Detect missing signatures, F2F documentation, or incomplete assessments.

1. Ongoing Education and Feedback

• Provide clinicians with examples of strong and weak narratives.
• Use MAC audit outcomes to refine templates and training.

7. Practical Narrative Template (Sample)

You can adapt the following as a documentation guide for clinicians:

A. Trigger / Why Hospice, Why Now

“Patient was referred to hospice on [date] following [event: e.g., 3rd hospitalization in 2 months for CHF exacerbation] despite [brief description of optimal management].”

B. Principal Diagnosis and Related Conditions

“Principal diagnosis: [condition]. Prognosis is further limited by [list comorbidities and how they interact to worsen prognosis].”

C. Objective Clinical Status (Current)

• PPS/Karnofsky: [score] on [date].
• Functional status: [describe mobility, ADLs, continence].
• Nutrition: [weight, % loss over time, intake].
• Symptoms: [dyspnea, pain, fatigue, cognition, sleep].
• Wounds: [location, stage, measurements, progression].
• Labs/diagnostics: [relevant trends].

D. Comparative Decline Since Last Certification

“Since last certification on [date], patient has [describe specific changes with measurements and dates]. Previously [prior status]; currently [current status].”

E. Despite Optimal Management

“Decline has occurred despite [current regimen, interventions, specialist care]. No further disease-modifying options are available/appropriate due to [reasons], and care is focused on comfort.”

F. Stability/Improvement (If Present)

“Although [specific symptom] has improved with [intervention], the patient remains at high risk for further decline due to [irreversible disease factors], and overall prognosis remains six months or less.”

G. Face-to-Face (If Applicable)

“Face-to-face encounter completed on [date] by [provider, credentials]. Findings included [key clinical observations] supporting a prognosis of six months or less. Attestation and signature are documented in the record.”

H. Prognosis Statement

“Based on the above findings, including [key data points], the patient has a medical prognosis of six months or less if the illness runs its normal course and remains appropriate for hospice services.”

8. The Path Forward

MAC scrutiny is increasing, and weak narratives are costly in denials and clawbacks. Agencies that succeed:

• Treat prognosis documentation as a clinical discipline, not a formality.
• Use structured, comparative, data-rich narratives.
• Implement pre-billing review and technology-enabled checks.

Brellium supports this by reviewing every record for certification of terminal illness and prognosis before you bill, flagging:

• Weak or missing decline narratives.
• Contradictions between narrative and data.
• Missing signatures and F2F documentation.
• Other gaps that undermine medical necessity.

The result is a defensible record that tells a clear, clinically grounded story of why hospice, and why now—and that story stands up to MAC review.