Part B Insider (Multispecialty) Coding Alert

Published on Mon Feb 21, 2011 PDF

Hospices that aren't documenting their long-stay hospice patients' terminal diagnoses carefully might as well say "goodbye" to their Medicare reimbursement for them.

Two ongoing edits of long-stay hospice patients' claims by Cahaba GBA have seen high denial rates, the carrier says in its March newsletter for providers.

Edit #1: Edit topic code 5037T targets claims with lengths of stay greater than 730 days, Cahaba explains in the Newsline. From October to December 2010, the edit saw a dollar denial rate of 69 percent, up from 53 percent a year ago.

Edit #2: Edit topic code 5048T selects claims with lengths of stay of 999 days, and "had a near consistent denial rate of 74 percent over the last year, including last quarter," Cahaba says.

For both edits, the top denial reason by an overwhelming margin was "the six-month [180 days] terminal prognosis not being supported in the documentation," Cahaba says.