Reimbursement:
Edits Hit Hospice Claims For Lymphoma, Myeloma Patients
Published on Sat Aug 21, 2010
How well does your documentation support patients' six-month prognosis? You need to sharpen your terminal illness documentation for certain long-stay cancer patients, or risk Medicare claims denials. Recent edits of such hospice claims at Cahaba GBA racked up high denial rates. The top denial reason was "5PTER: Documentation doesn't support six-month terminal prognosis," the regional home health intermediary notes in its September newsletter to providers. Other main reasons for denials were "5PCER: Certification issues" and "56900: No response to ADR," the RHHI explains. Edit #1: Edit 5065T looked at claims for patients with a primary diagnosis of 202.xx-203.xx (lymphomas and myelomas), stays exceeding 180 days, and routine level of services, Cahaba says. The edit resulted in a 59 percent denial rate. Edit #2: Edit 5013T reviewed claims for patients with a primary diagnosis of 290.40 (Vascular dementia), stays exceeding 240 days, and routine level of services, Cahaba says. The denial rate [...]