Life Support Issues/ADR's



My name is Carol Matthews. I am a family/psychiatric NP in Springfield MO. I have been doing re-certifications for a local hospice since Jan. 2011.

I think we join many other US Hospices now experiencing the need to write more and more ADR's. I want to do my best for our patients and present their cases clear and concisely. Do you have a charting format and/or "points to make" in a logical order?

I appreciate your help. Happy Thanksgiving.

Thanks for your coming help,

Dr. Carol Matthews  

Hello Carol,
It is so nice for me to see someone wanting to improve in this area. Yes indeed, ADRs are here to stay and they serve as a wake-up call for hospices to mindfully consider what it is exactly that makes a patient eligible for hospice. I donít really have something written down on paper that I can send to you.  I have a power point presentation from a national conference that I would be happy to email you if you send me your email address. Mine is

The best advice I can give is this:

1) Use your Local Coverage Determination as a framework in documenting. Speak their language, not your own.   Use the LCD specific to your Medicare Administrator Contractor, Cigna, Palmetto etc.  The nurse reviewer may have little end of life training but she is using that document as a recipe to determine hospice eligibility.  At each recertification or face to face visit, start with the hospice terminal diagnosis specific information (like Alzheimerís) and summarize each active comorbid condition with their related symptoms (COPD, CHF, etc.).

2) Measure all decline within the past 6 months using objective tools.  Objective data is given more weight than subjective. Weights, mid-arm circumferences, changes in FAST, PPS, KPS, and NYHA class, etc.   Pay close attention to subtle changes in functional decline.  Things like increases in time spent eating due to dysphagia, increases in time spent lying in bed vs. sitting in chair, increases in time spent sleeping.  All of the above demonstrate increasing weakness.  If the patient improved, take credit for it! Document what the hospice did that helped the patient to improve.  Short term improvement (such as weight gain) is not a reason to discharge if the patient shows decline in other areas.      

3) Make sure that your hospice has chosen the best possible hospice diagnosis.  For example, patients with debility must show weight loss.  This is not negotiable. Sometimes those same patients easily meet the criteria for Alzheimerís disease and related disorders but donít meet the criteria for Debility.

I hope that this helps.  If you want to talk about it on the phone, I am happy to share what I know. It is important to me that eligible patients receive hospice care.  My email address is above.  

Life Support Issues

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Betsy Murphy


My expertise is in end of life care for adults. Identifying when someone is approaching the end of their life. Benefits and burdens of end of life treatments. Managing pain and other symptoms. Providing care for dying patients at home. Advocating for someone who is dying in a hospital or nursing home.


More than 28 years of experience in hospice care. Currently consulting with hospices to promote access for patients to receive hospice care earlier in the course of their illness. Betsy provides training for hospice marketing staff to effectively work with nursing facilities to help identify eligible patients. She writes Additional Development Request (ADR) letters to Medicare to help hospices get paid for their services and to avoid future claim denials.

Hospice and Palliative Nurses Association

Articles: Clinical Reviews, Advance for Nurses, Nursing Spectrum, Washington Business Woman,; Understanding Medical-Surgical Nursing (FA Davis and Company), Guide to Caregiving in the Final Months of Life (TM Brown publishers).

Bachelors of Science in Nursing, additionally trained as a Family Nurse Practitioner and certified as a hospice and palliative care nurse.

Awards and Honors
Outstanding Woman in Loudoun County (VA) by Loudoun County Commission on Women 1997 and 2002.

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