Eli's Hospice Insider

"The majority of the denials received by providers were related to the six-month [180 days] terminal prognosis not being supported in the documentation," CGS says in its provider newsletter. "Documentation is essential in supporting the beneficiary meets this prognosis, especially for patients that have remained on the hospice benefit for an extended length of time, or those patients that have chronic illnesses or general decline."

Figuring out when a long-stay patient no longer qualifies can be tricky. But "if a patient improves or stabilizes sufficiently over time while in hospice such that he/she no longer has a prognosis of six months or less from the most recent recertification evaluation or definitive interim evaluation, that patient should be considered for discharge from the Medicare hospice benefit," says CGS's Local Coverage Determination (LCD), "Determining Terminal Status" (L32015).

Hospices protest that patients end up being penalized for stabilizing under hospice care. But "such patients can be re-enrolled for a new benefit period when a decline in their clinical status is such that their life expectancy is again six months or less," CGS says in the LCD.

Not all patients who stabilize need to be discharged, however, the LCD allows. "Patients in the terminal stage of their illness who originally qualify for the Medicare hospice benefit but stabilize or improve while receiving hospice care, yet have a reasonable expectation of continued decline for a life expectancy of less than six months, remain eligible for hospice care."