Eli's Hospice Insider

Published on Fri Nov 27, 2009 PDF

Is your documentation tanking your claims?

At least one Regional Home Health Intermediary (RHHI) is taking notice of patients with organic brain syndrome and a long length of stay. Find out how you can prevent denials. Between July 1 and September 30, RHHI Cahaba GBA reported a denial rate of nearly 63 percent for patients with a diagnosis of organic brain syndrome (OBS) and a length of stay greater then 240 days.

The top denial reason for these patients, pulled due to a widespread  edit, was "six-month terminal prognosis not supported in the documentation,"Cahaba noted in its December newsletter for providers.

Patients with OBS may be appropriate for hospice, however, documentation must support the six month prognosis, Cahaba said.

Tip: Refer to the hospice Local Coverage Determination (LCD) for help in determining which symptoms support the terminal prognosis.

A medical record that demonstrates good documentation has the following characteristics, the RHHI advised:

• Includes clinical factors and descriptive notes that demonstrate the patient's illness is terminal and would reasonably indicate a life expectancy of six months or less.

• Is complete, contains prompt and accurate documentation, is accessible and organized.

• Records all services, whether furnished directly or under arrangements made by the hospice.

• Notes from multiple disciplines involved in caring for the patient paint a picture of the beneficiary's terminal progression without using vague statements such as "slow decline" or "disease progressing."

Good news: Cahaba points out that hospice benefit periods are unlimited as long as the above items hold true.

The RHHI also notes that while most beneficiaries will show decline from one certification period to the next, this isn't the case for beneficiaries whose condition doesn't run the normal course of decline. These patients may remain temporarily unchanged but it should be clear that the beneficiary has a six-month prognosis in the medical record.

Resource: Cahaba's hospice LCD "Hospice -- Determining Terminal Status" is available from the Centers for Medicare & Medicaid Services (CMS) Web site at www.cahabagba.com/rhhi/coverage/lcds/lcd_active.htm.