Home Health & Hospice Week

Reviewers deny 70% of reviewed claims for prognosis, other problems.

You'd better make sure your documentation of long-stay patients' terminal illness is pristine or face major claims denials.

Medical reviewers at regional home health intermediary Cahaba GBA denied about 70 percent of claims in two recent hospice reviews, mainly for problems with the six-month prognosis. And more scrutiny is on the way--a lot more.

The first review looked at claims for patients with a primary diagnosis of 414.00 (Coronary atherosclerosis of unspecified type of vessel, native or graft) and stays longer than 180 days. The second review examined claims for patients with revenue code 0651 (routine home care) and stays longer than 730 days.

In the diagnosis code probe, reviewers denied a whopping 87 percent of claims due to "the six-month terminal prognosis not being supported," Cahaba says in its April newsletter to providers. In the revenue code probe, reviewers shot down 71 percent of claims for that reason.

"Documentation is essential in 'painting the picture,' 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," Cahaba tells providers. "These diagnoses alone may not support a six-month or less life expectancy, and documentation is depended upon to show why the patient is hospice appropriate."

Warning: Don't slack off on documentation as time goes by. "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 directs.

Hospices are getting some sympathy from lawmakers on the difficulties of determining a six-month prognosis. Lawmakers in March introduced legislation that would place a three-year moratorium on retroactive repayments from hospice providers to Medicare and authorize a study of the hospice benefit, according to press reports.

A recent Medicare Payment Advisory Commission analysis projected that 220 hospices, or about one in every 13 providers, in 2005 received repayment demands totaling $166 million, according to the Kaiser Family Foundation.

But MedPAC isn't likely to be hospices' friend this legislative session. The Commission has expressed its desire to freeze or cut hospice payments with a "blunt instrument," according to a recent meeting (see Eli's HCW, Vol. XVII, No. 11).

Get Ready For More Review

Documenting terminal illness in clinical notes isn't hospices' only problem. Reviewers for the Cahaba revenue code probe also denied 13 percent of claims for "missing, incomplete or untimely certification," the intermediary says in the April Newsline.

Reviewers denied another 10 percent of claims in that probe for missing or incomplete election statements. The election statement must include your hospice's identification; the patient's acknowledgement of an explanation of the benefit; the effective date of the election and the patient's signature, Cahaba reminds providers.

In the diagnosis code probe, reviewers denied 10 percent of claims due to non-response to the additional development request (ADR).

Watch out: Due to the high denial rates found in each probe, Cahaba is initiating a continuing widespread review for the diagnosis code edit (topic code 5036T) and the revenue code edit (5037T), it says.

Another one: And the intermediary "will soon be conducting a widespread review on hospice claims," it warns in a March 31 post to its Web site. "This edit is set to select hospice claims with a length of stay greater than 999 days (2.75 years). The topic code for this review will be 5005W."

That's not all: Cahaba will also review hospice claims with revenue code 0656 (general inpatient services) and hospice claims with a primary diagnosis of 425.4 (Primary cardiomyopathy NEC) and a length of stay greater than 181 days, it says on its Web site. The codes for the reviews will be 5004W and 5006W, respectively.

Note: More information is in the Cahaba bulletin at https://www.cahabagba.com/part_a/education_and_outreach/newsletter/200804_rhhi.pdf and on Cahaba's Web site at www.cahabagba.com/part_a/whats_new/news_cahaba.htm.