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Eli's Hospice Insider

Medical Review:

Focus On These Medical Review Hot Spots To Fend Off Denials

Published on Mon Apr 16, 2012

Expect scrutiny for claims with dementia as the primary diagnosis.

Denials for terminal illness-related problems are topping the charts for hospices, but you can sidestep such landmines with strengthened charting and coding.

About 40 percent of hospice claims denied are due to documentation failing to support the terminal illness, explained Latesha Walker with the Centers for Medicare & Medicaid Services at the National Association for Home Care & Hospice's annual March on Washington conference. And 39 percent of hospice claims denied are due to the diagnosis code not supporting the terminal illness, said Walker, director of CMS's Division of Medical Review and Education.

Medical reviewers are also finding problems with the hospice face-to-face requirement, Walker noted in the March 26 panel.

And reviewers are seeing deficiencies with the physician narrative required for certification and recert, Walker added. Problems range from the technical (lacking a date or signature) to the clinical (failing to explain why the clinical findings support the patient's life expectancy of six months or less).

Tip: Handwritten, electronic and faxed signatures are all OK, HHH Medicare Administrative Contractor CGS explains in an educational article on its website. But stamped signatures are not, the MAC warns. Get more cert and recert tips from CGS at www.cgsmedicare.com/hhh/coverage/Coverage_Guidelines/CERT_ReCERT_Requirements.html.

Walker also revealed the hospice topics Medicare medical reviewers plan to focus on in the future. Topping the list is claims with dementias as a primary diagnosis.

Claims with failure to thrive will also come under reviewers' microscope, Walker said. And claims for long-stay patients (180 days or more) will undergo extra scrutiny.

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