Hospice Length of Stay — Widespread Probe Results and Review Notification
As a result of the analysis of errors related to the widespread probe review for topic 5005W for claims reviewed between April 1, 2008, through July 31, 2008, Cahaba will be initiating a continuing widespread review for hospice providers. The topic code for this review will be 5048T, and will select hospice claims with a length of stay greater than 999 days (2.75 years). Claims will be selected across the provider community billing these services that meet the parameters of the edit. Once selected, the claims will be reviewed for medical necessity (e.g., compliance with CMS guidelines, contractor local coverage determinations (LCDs), correct billing and coding). Results of the widespread probe review are summarized below.
Denials were related to missing, incomplete or untimely certifications and also to the six-month terminal prognosis not supported in the medical record.
An individual is eligible for the Medicare hospice benefit when the hospice agency obtains a valid physician’s certification stating that the patient has a terminal illness with a life expectancy of six months or less if the terminal illness runs its normal course. For the first 90-day period of hospice coverage, the hospice must obtain a certification of the terminal illness by the medical director of the hospice or the physician member of the hospice interdisciplinary group and the individual’s attending physician if the individual has an attending physician. For subsequent periods, the certification statement must be obtained from the medical director of the hospice or the physician member of the hospice’s interdisciplinary group. If the hospice can not obtain the written certification within two calendar days of the beginning of the certification period, the hospice must obtain verbal certification within the two days. There are no standardized forms for this certification.
The actual dates for the certification period for which the physician is signing must be clearly stated on the form. Simply having the statement “third benefit period” is not enough to be able to tell which certification period the physician is signing. Each certification period must have the exact certification dates listed. For example “recertification statement for the period 3/1/07-4/29/07” is acceptable; however, “Recertification statement, 3rd benefit period” is not acceptable. If the date span for which the physician is certifying cannot be identified, your claim may be denied. Please take the time to review your agency’s certification and recertification forms and make sure there is a place on the form to document the exact certification period dates.
The Centers for Medicare & Medicaid Services (CMS) Medicare Benefit Policy Manual, (CMS Pub. 100-02), Ch. 9, states an individual is eligible for the Medicare hospice benefit when that individual has a terminal illness with a life expectancy of six months or less if the terminal illness runs its normal course. Documentation is essential in “painting the picture,” especially for patients that have remained on the hospice benefit for an extended length of time, or the patients that have chronic illnesses or general decline. These diagnoses alone may not support a six-month or less life expectancy, and documentation is depended upon to show why the patient is hospice appropriate. The LCD for Hospice, “Determining Terminal Status,” is helpful in identifying guidelines for hospice coverage for patients, and provides some documentation suggestions. The patient’s appropriateness for the hospice benefit must be clearly supported in the medical record from admission and throughout the hospice care provided.
For additional information, refer to the Medicare Benefit Policy Manual (CMS
Pub 100-02), Ch. 9, 
which can be found on the CMS Web site.
Page last updated: August 20, 2008
