Eli's Hospice Insider

Published on Fri Jun 13, 2014 PDF

Can your records back up the patient’s six-month prognosis?

If you’re submitting hospice claims that have a length of stay ranging from 150 to 365 days, you’d better make sure you can back them up with documentation of the prognosis.

In the first quarter of this year, HHH Medicare Administrative Contractor CGS denied a whopping 69 percent of claims reviewed with this LOS, in a new edit. CGS also denied 63 percent of claims selected by an edit targeting nursing home patients with a stay longer than 180 days and a primary diagnosis of debility unspecified – and 44 percent of claims for patients with LOS longer than 730 days, CGS says in its May newsletter for providers.

The top denial reason is “due to the common obstacle of documenting a six-month terminal prognosis,” CGS says in the Medicare Advisory. “Detailed documentation is essential for patients that have remained on the hospice benefit for an extended length of time, or for patients that have chronic illnesses or general decline.”

“The patient’s appropriateness for the hospice benefit must be clearly supported in the medical record from admission and throughout the course of hospice care provided,” CGS continues. “Although the patient’s clinical condition upon admission to hospice may have supported the trajectory of decline to be six months or less, it is important to ensure the documentation for patients with long lengths of stay clearly supports an on-going trajectory of decline versus a chronic stable patient with significant custodial care needs whose trajectory has plateaued.”

Tool: CGS offers tips to improve hospice documentation at www.cgsmedicare.com/hhh/education/materials/pdf/hospice_Documentation_Tool_H-021-01_07-2011.pdf.