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Documentation:

Beef Up Documentation For OBS Patients With These 8 Steps

Published on Fri Jan 14, 2011

The more objective measures you use, the better off you'll be in medical review.

You'd better focus on showing why your long-stay organic brain syndrome patient still qualifies for the benefit, or risk throwing away thousands of dollars in Medicare reimbursement.

A widespread edit of hospice claims with a primary diagnosis of 294.8 (Organic brain syndrome) and length of stay exceeding 240 days turned up a 64 percent denial rate, HHH Medicare Administrative Contractor CGS reports in its December provider newsletter (see related story, this page). The edit shows why you need to strengthen your documentation for such patients.

Tip: "You should argue anew the case for hospice eligibility with each recert," said RNs Beth Noyce and Dana Walling of Ogden, Utah-based Applegate HomeCare and Hospice of Utah in a presentation at this fall's National Association for Home Care & Hospice annual meeting in Las Vegas.

You must make your argument on paper to avoid claims denials, Noyce and Walling said in the presentation for their Oct. 4 session, "Hospice Widespread Edits." "The medical record's documentation must explain why the beneficiary still has a six-month prognosis."

Follow these tips to improve your documentation and fend off denials in medical review:

1. Don't get sloppy. Your clinicians should document every case as if it will be audited, Noyce and Walling urged.

Clinicians have a tendency to slack off on charting with a well established patient. "The patient's appropriateness for the hospice benefit must be clearly supported in the medical record from admission and throughout the hospice care provided," CGS emphasizes in the newsletter.

2. Get specific. Avoid vague terms like "slow decline" and "disease progressing," Noyce and Walling advised. Instead, CGS wants to see quantifiable values or measures, it says in a tool on its website, "Suggestions for Improved Documentation to Support Medicare Hospice Services." (For examples of such measures, see box on p. 4.)

3. Use LCDs. Use Local Coverage Determination criteria when you can in your documentation, suggested Provider Insights Inc. founder Annette Lee and Noyce in a separate presentation at the NAHC annual meeting, "Medical Review in the New Hospice Environment."

Tool: For a link to a PDF copy of CGS's LCD on terminal prognosis, e-mail editor Rebecca Johnson at rebeccaj@eliresearch.com with "Terminal Prognosis LCD" in the subject line.

4. Address improvements. Don't just ignore the occasions when your patient improves in an area rather than declining, Lee and Noyce recommended in their Oct. 2 session. Address anything that can be seen as an improvement.

For example: If your patient gains weight, explain in the documentation how hospice care has facilitated more caloric intake compared to pre-admission, Lee and Noyce said in the presentation. But then point out how far below a healthy weight the patient remains. And make note of things like "an appetite allowing only coffee and candy cannot be expected to restore this terminally ill patient to a well nourished state."

5. Don't limit yourself time-wise. It may drive you crazy when you get a non-terminal denial for a patient who has since died. Remember that an additional development request (ADR) may ask for records from a certain timeframe, but you are free to include more recent documentation that shows a later decline, Lee and Noyce offered.

Pointer: Put the date of death on the first page of an appeal, they advised.

6. Push education. Your clinicians won't magically become A+ documenters on their own. You'll need to use general education and individual coaching to get them where they should be, Noyce and Walling pointed out.

7. Check yourself. Use self-audits to find and correct problems before reviewers do, Noyce and Walling counseled. And you can use recert as a time to make sure the beneficiary still qualifies and your documentation still shows that.

8. Bite the bullet. It may not be easy, but if the patient doesn't qualify at recert you'll have to let her go. "Avoid recerts that show no decline," Noyce and Walling advise.

If you fail to discharge a patient when she is no longer eligible, you'll be courting problems ranging from claims denials to survey deficiencies to fraud charges, experts warn.

Note: You can access a Hospice ADR checklist at the end of Lee and Noyce's slides at www.nahc.org/Meetings/AM/11/Handouts/215.pdf

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