Home Health & Hospice Week

‘Terminal illness not supported’ shot down over half of claims in latest MAC TEP round.

With hospice claims getting more scrutiny than ever, you’ll want to make sure you are protected against one of the biggest claim-killers — failure to document terminal illness.

Reminder: “When a beneficiary’s record is selected by a Medicare contractor for review, it is the responsibility of the hospice provider to demonstrate in the documentation that the services rendered and billed were medically necessary,” HHH Medicare Administrative Contractor Palmetto GBA notes in guidance on its website. “In the case of hospice, this means that the documentation should show that the individual has a medical prognosis that his or her life expectancy is six months or less if the illness runs its normal course.”

A critical piece of that documentation is the certification of terminal illness (CTI), Amy Lee Smith, director of internal audit for Bon Secours Mercy Health based in Cincinnati, noted at the AAPC Healthcon 2023 conference in Nashville, Tenn. “There are a whole lot of documentation requirements” for the CTI, Lee Smith said in her May 23 session, “Grand Ole Tips for Home Health and Hospice Documentation and Coding.”

The latest Targeted Probe and Educate medical review stats from HHH MAC CGS show why this is such a pain point for hospices. “‘Terminal prognosis not supported’ accounted for 50.50 percent of the total TPE denials” in its most recently released review data for the year ending in August 2022.

“Starting with proper certification of terminal illness (CTI) is critical,” CGS emphasizes in education it sent to hospices earlier this year.

Beware: Hospices need a new CTI for each benefit period, Lee Smith pointed out. Don’t get mixed up between benefit periods and billing periods, she added. The benefit starts with two 90-day periods, then switches to unlimited 60-day periods. The fact that they don’t sync with the requirement to bill every 30 days is confusing, she cautioned.

The CTI requires six elements, CGS notes (see box, p. 147). And each of those elements contains land mines that could blow up your hospice claim.

For example, your CTI content might be great, but you miss the deadline. “The hospice must obtain verbal or written certification of the terminal illness, no later than 2 calendar days (by the end of the third day) after the start of each benefit period (initial and subsequent),” CGS instructs on its Hospice Certifi­cation/Recertification webpage. On the other end, “initial certifications may be completed up to 15 days before hospice care is elected. Recertifications may be completed up to 15 days before the start of the next benefit period,” CGS says.

Exception: “If written certification/recertification cannot be obtained within 2 calendar days, verbal certification must be obtained,” CGS says. Don’t forget, “the hospice must determine who may accept verbal certification from a physician in compliance with state and local law regulations,” the MAC adds.

When obtaining verbal orders, “the hospice must ensure the written certification/recertification is signed and dated prior to billing Medicare, or their claim(s) may be denied,” CGS warns.

“There’s a whole timeline of things” hospices must observe in the CTI process, Lee Smith stressed.

Another pitfall is the mere placement of the physician narrative within the CTI. The narrative must go “right above the signature,” Lee Smith emphasized.