5CF36, 5FF36: 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 less 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 may be viewed on the Palmetto GBA Web site at www.PalmettoGBA.com/HHH. 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

More Information

• CMS Internet-Only Manuals (IOMs), Publication 100-02, Medicare Benefit Policy Manual, Chapter 9, Section 10 (PDF)
• CMS Internet-Only Manuals (IOMs), Publication 100-04, Medicare Claims Processing Manual, Chapter 11, Section 10 (PDF)
• Palmetto GBA LCDs