Eli's Hospice Insider

Published on Tue Jul 17, 2012 PDF

Pointer: Use your own docs to persuade colleagues to improve documentation.

So often for hospice patients, claims denials hinge on the patient's certification or recert. Look to recent results from the Comprehensive Error Rate Testing program to help you avoid cert landmines.

In the latest time period, "all CERT errors for hospice providers were related to the hospice certification/recertification," says HHH Medicare Administrative Contractor CGS in its June newsletter for providers. Sometimes hospices simply failed to submit the cert to the CERT contractor. But in other cases, the cert had other problems.

Example #1: For one patient, the CERT contractor found the documentation to be insufficient. The documentation "lacked the specific clinical findings and explanation of why the clinical factors supported the six month prognosis," CGS explains.

The hospice under CERT review is hardly alone. "The most common problem area that we see is insufficiently documented certifications," says consultant Beth Carpenter with Beth Carpenter and Associates in Barrington, Ill.

Example #2: For another patient, the cert was late. "The physician's certification was not received until 2 weeks after hospice care began," CGS notes.

Don't forget: "According to the Medicare Benefit Policy Manual, the hospice must obtain oral or written certification of the terminal illness no later than 2 calendar days after hospice care is initiated, and must be signed prior to the submission of the claim," CGS reminds hospice providers.

Step Up Your Education Efforts

Carpenter offers this advice to reduce CERT-related denials:

1. Educate. Implement in-depth orientation and annual inservices for medical directors and physician designees, Carpenter counsels. The training should cover appropriately documenting the certification narrative.

2. Go by the book. Supply medical directors and physician designees with Local Coverage Determinations (LCDs), Carpenter adds. The policies spell out what is required in documentation.

Resource: You can access each MAC's LCDs on their websites at www.cgsmedicare.com/hhh/coverage/Coverage_Guidelines/LCD.html for CGS, www.ngsmedicare.com/wps/portal/ngsmedicare/mpc for National Government Services, and www.palmettogba.com/medicare for Palmetto GBA -- select "J11 MAC -- Home Health and Hospice" in the left column, then click on "Medical Policies" in the left column and choose "LCDs and NCDs" from the drop-down menu.

3. Police yourself. Find your mistakes before reviewers do -- while you can still fix many errors and receive your rightful reimbursement in a timely manner. Audit 100 percent of all certifications and recertification, as well as all face-to-face documentation, Carpenter urges.

4. Use your docs. Finding that you're hitting a brick wall when it comes to persuading certain referral sources to beef up their documentation? Turn to a critical resource for help -- your own physician advocates. "Ask the medical directors, physician designees and team physicians to perform peer review," Carpenter recommends.