Eli's Hospice Insider

Published on Tue Apr 26, 2011 PDF

Documentation is the key in getting reimbursed for long stays.

Hospices that aren't documenting their long-stay hospice patients' terminal diagnoses carefully might as well say "good-bye" to their Medicare reimbursement for them.

Two ongoing edits of long-stay hospice patients' claims by regional home health intermediary Cahaba GBA have seen high denial rates, the RHHI says in its March newsletter for providers.

Edit #1: Edit topic code 5037T targets claims with lengths of stay greater than 730 days, Cahaba explains in the Newsline. From October to December 2010, the edit saw a dollar denial rate of 69 percent, up from 53 percent a year ago.

Edit #2: Edit topic code 5048T selects claims with lengths of stay of 999 days, and "had a near consistent denial rate of 74 percent over the last year, including last quarter," Cahaba says.

For both edits, the top denial reason by an overwhelming margin was "the six-month [180 days] terminal prognosis not being supported in the documentation," Cahaba says.

"Documentation is essential in supporting the beneficiary meets this prognosis, especially for patients that have remained on the hospice benefit for an extended length of time, or the patients that have chronic illnesses or general decline," the intermediary stresses. "These diagnoses alone may not support a six month or less life expectancy, and documentation is depended upon showing why the patient is hospice appropriate."

Don't get sloppy with documentation in a patient's later days because it seems obvious why the patient qualifies for hospice. "The patient's appropriateness for the hospice benefit must be clearly supported in the medical record from admission and throughout the hospice care provided," Cahaba reminds hospices.

Resource: Cahaba's quick reference took for improving hospice documentation is at http://www.cahabagba.com/rhhi/education/materials/quick_hospice_doc.pdf.

Plus: Although Cahaba denied a much smaller percentage of long-stay claims for certification problems, it was the second-highest reason for denials in both edits, Cahaba notes. Those cert-related denials may increase after the face-to-face requirement starts being enforced April 1, experts predict.