Hospice Medical Review Top Denial Reason Codes:

The claim has been fully or partially denied as documentation submitted for review did not include a plan of care (POC) for all or some of the dates billed.

How to prevent this denial

• The hospice must submit POCs for dates of service billed when responding to ADR request
• All dates billed must be covered by a POC to be payable under the Medicare hospice benefit
• If more than one POC covers the dates of service in question, submit all the related plans of care for review
• The POC must contain certain information to be considered valid. This includes:
o Scope and frequency of services to meet the beneficiary’s/family’s needs
o Beneficiary specific information, such as assessment of the beneficiary's needs, management of discomfort and symptom relief
o Services that are reasonable and necessary for the palliation and management of the beneficiary’s terminal illness and related conditions

The POC must specify the hospice care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment.

All hospice care and services must follow an individualized written plan of care.

The POC must be reviewed, revised and documented as frequently as the beneficiary's condition requires, but no less frequently than every fifteen (15) calendar days.

Not Hospice Appropriate
The claim has been fully or partially denied because the documentation submitted for review did not support prognosis of six months or less.

How to prevent this denial:
• Ensure a legible signature is present on all documentation necessary to support six-month prognosis
• Submit documentation for review to provide clear evidence the beneficiary has a six-month or fewer prognoses which supports hospice appropriateness at the time the benefit is elected, and continues to be hospice appropriate for the dates of service billed
• Palmetto GBA has a Local Coverage Determination (LCD) for some non-cancer diagnoses. Submit documentation which supports the coverage criteria outlined in the policy. LCDs are available under 'Medical Policies.' If documenting weight loss to demonstrate a decline in condition, include how much weight was lost over what period of time, past and current nutritional status, current weight and any related interventions.
• Document any co-morbidity, which may further support the terminal condition of the beneficiary and the continuing appropriateness of hospice care

Physician Narrative Statement Not Present or Not Valid

The claim has been denied as the physician narrative statement is not present or not valid.

How to prevent this denial:
• The physician must include a brief narrative explanation of the clinical findings that supports a life expectancy of six months or less as part of the certification and recertification forms, or as an addendum to the certification and recertification forms
• If the narrative is part of the certification or recertification form, then the narrative must be located immediately prior to the physician’s signature
• If the narrative exists as an addendum to the certification or recertification form, in addition to the physician’s signature on the certification or recertification form, the physician must also sign immediately following the narrative in the addendum
• The narrative shall include a statement under the physician signature attesting that by signing, the physician confirms that he/she composed the narrative based on his/her review of the patient’s medical record or, if applicable his or her examination of the patient
• The narrative must reflect the patient’s individual circumstances and cannot contain check boxes or standard language used for all patients