Medicare Compliance & Reimbursement

Ensure that your documentation for patients living longer than the six-month prognosis stands up to scrutiny.

With Medicare clamping down on payments for long-stay hospice patients, you need to figure what when your patient no longer qualifies for the terminal diagnosis before an edit hits you and you are faced with a denial.

Examples: Home Health & Hospice Medicare Administrative Contractor CGS has revealed the results of two edits of long-stay patients. Under edit topic code 5037T, CGS reviewed claims for hospice patients with lengths of stay greater than 730 days and denied 81 percent of reviewed claims. Under edit topic code 5048T, CGS reviewed claims for hospice patients with LOS greater than 999 days and denied a whopping 97 percent of claims.

The stats suggest that medical reviewers are getting tougher on long-stay patient claims. The denial rates are up from 69 and 73 percent from the year-ago time period, respectively, CGS reports.

"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."

Remember: "These diagnoses alone may not support a six-month or less life expectancy, and documentation is dependent upon showing why the patient is hospice appropriate," CGS tells providers.

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."