Eli's Hospice Insider

Published on Thu Jan 21, 2016 PDF

Warning: Dementia patients at high risk.

Hospice claims are subject to more scrutiny every day, especially for patients who exceed the six-month timeframe. Failing to document these patients’ terminal condition makes their claims low-hanging fruit for medical reviewers.

“Medicare coverage of hospice depends on a physician’s certification that an individual’s prognosis is a life expectancy of six (6) months or less if the terminal illness runs its normal course,” says HHH Medicare Administrative Contractor CGS in a recent article on its website. “It is important that the medical records support the physician’s six (6) month prognosis.”

But often, CGS medical reviewers find that “the documentation is … insufficient to support the terminal prognosis,” the MAC reports.

The problem: Often, “the medical record lacks documentation to show further decline,” CGS says.

“If your documentation doesn’t reflect a 6 month or less prognosis (usually evidenced by clinical decline) you are at risk for payment denial,” warned physician David Fedor, Medical Director for Palliative Care at McKay Dee Hospital, System Medical Director of Palliative Care for Intermountain Healthcare, and Medical Director for Envision Hospice, in a presentation at the Utah Hospice & Palliative Care Organization’s November convention.

The solution: “Since determination of decline presumes assessment of the patient’s status over time, it is essential that both baseline and follow-up determinations be reported where appropriate,” CGS urges. In other words, staff need to be recording concrete data points in the patient record (see related cover story for tips).

“It is critical that hospices document measurable decline, most especially with a non-cancer diagnosis,” offers nurse consultant Lynda Laff with Laff Associates in Hilton Head Island, S.C.

Targets: “With a primary or terminal diagnosis of Alzheimer’s, it is very important that documentation clearly identifies decline,” Laff says. “This diagnosis and dementia diagnoses will be the first to be audited.”