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Hospice
Diagnosis Related
Frequent hospice denials occur because providers are not following the established guidelines in the local coverage determination (LCD) for terminal prognosis when providing hospice services to beneficiaries with diagnoses of dementia, cardiac disease, nutritional/metabolic disorders, and debility.

Length of Stay/Continuous Care

Frequent hospice denials occur because providers are not following the established guidelines in the LCD for terminal prognosis.

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Marked Reimbursement Changes

Denials occur due to providers lack of understanding related to the Centers for Medicare & Medicaid Services guidelines for provision of hospice services and the established LCD guidelines for terminal prognosis for various diagnoses.

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Understanding Technical Denial Reason Codes for Hospice Claims

Medical Review audits are preformed to ensure providers documentation adheres to Medicare coverage guidelines. During recent medical review audits, several problems were identified causing technical denials for denial reason code 55H1B; untimely certification/recertification; 55H1F lack of valid physician certification, and 55H1G beneficiary Notice of Election did not meet statutory/regulatory requirement. 55H1B-Untimely Certification/Recertification Causes for denials: Physician signature(s) not dated No verbal or oral statement documented in the medical record Physician signature(s) not dated: A date must follow the certifying physicians signature to show timeliness. Medical review can no longer accept stamp received dates or fax stamp dates as validation of timeliness. Reference: CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 9, http://www.cms.gov/manuals/Downloads/bp102c09.pdf. (319 KB)

No verbal or oral statement documented in the medical record: If a written certification of terminal illness is not obtained within two days (that is, by the end of the third day) a hospice provider/facility must obtain an oral/written statement of terminal illness and admission to the hospice provider/facility. The verbal statement must be documented in the beneficiarys medical record. The verbal statement of initial certification must be signed and dated by the hospice medical director or physician member of the hospice interdisciplinary group (IDG) and the individuals attending physician. Reference: CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 9 Section 20.1 Timing and Content of Certification, http://www.cms.gov/manuals/Downloads/bp102c09.pdf. (319 KB) 55H1F-Lack of valid physician certification Causes for denials: Certification of terminal illness lacks the certification dates The initial certification lacks the appropriate physician signatures Certification of terminal illness lacks the certification dates: The Physician Certification/Recertification of Terminal Illness (PCTI) is a required document for eligibility of the Medicare hospice benefit. As of January 1, 2011, the physician certification of terminal illness must be signed and dated by the physician and the dates identifying the certification period must appear on the form. When documenting the certification period you must identify the actual certification dates and not the certification period. Reference: CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 9 Section 20.1 Timing and Content of Certification, http://www.cms.gov/manuals/Downloads/bp102c09.pdf. (319 KB) The initial certification lacks the appropriate physician signatures:

The initial certification lacks the appropriate physician signatures: The initial certification requires two physician signatures and signatures must be dated. The initial certification requires the signature of the hospice medical director or a physician member of the hospice IDG, and the individuals attending physician if the individual has an attending physician. In the case where the hospice medical director is also the beneficiarys attending physician a statement must be made on the certification. Reference: CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 9 Section 20.1 Timing and Content of Certification, http://www.cms.gov/manuals/Downloads/bp102c09.pdf. (319 KB) 55H1G-Beneficiary Notice of Election did not meet statutory/regulatory requirement Cause for denials: Beneficiary election consent lacked proper acknowledgments that the hospice services are palliative in nature rather than curative Beneficiary signatures are on a separate sheet of paper from the acknowledgement statements Beneficiary election consent lacked proper acknowledgments that the hospice services are palliative in nature rather than curative: The beneficiary election statement must contain language that the beneficiary was given their proper acknowledgement that the hospice services are palliative in nature rather than curative. Reference: CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 9 Section 20.2 - Election, Revocation, and Change of Hospice, http://www.cms.gov/manuals/Downloads/bp102c09.pdf. (319 KB) Beneficiary signatures are on a separate sheet of paper from the acknowledgement statements: Beneficiary election statements are often a two-sided form. The acknowledgements are typically on the front and the beneficiary signs the back of the form. During the copying or scanning process, this form often becomes two single sheets of paper. If you are using a two-sided form, make sure the form states page 1 of 2 and page 2 of 2, so during a medical review audit a reviewer can tell this was a two-sided form and the beneficiary was given their proper acknowledgement.

Last Modified: 10/25/11

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