Eli's Hospice Insider

Will your documentation support patients' six-month prognosis?

Get ready to beef up 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 sixmonth 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 for this edit was 63 percent.

"Documentation is essential in 'painting the picture,' especially for patients that have remained on the hospice benefit for an extended length of time, or for patients that have chronic illnesses or general decline," Cahaba stresses.

"These diagnoses alone may not support a six-month or less life expectancy; therefore, documentation is depended upon to show why the patient is hospice appropriate."

Resource: Refer to Cahaba's "Hospice Documentation Checklist" tool for help in improving your six-month prognosis documentation, the RHHI recommends. The checklist is at www.cahabagba.com/rhhi/education/materials/quick_hospice_doc.pdf. The edits show that certifications are causing big trouble for some hospices. That includes the new physician narrative that the Centers for Medicare & Medicaid Services started requiring last October.

Tip: "Cahaba's Medical Review department recommends dating each certification and recertification with the range of dates covered to avoid errors and denials," the intermediary says. "Simply having the statement 'third benefit period' is not enough to be able to tell which certification period the physician is signing."

For example: Each certification period must have the exact certification dates listed. "'Recertification statement for the period March 1, 2010, (60 days),' or 'recertification statement for the period March 1, 2010 - April 29, 2010,' is acceptable," Cahaba explains. "However, 'recertification statement, 3rd benefit period' is not acceptable."