Hospice Medical Necessity Tips for Medical Record Review

When a beneficiary’s record is selected by a Medicare contractor for review, it is the responsibility of the hospice provider to demonstrate in the documentation that the services rendered and billed were medically necessary. In the case of hospice, this means that the documentation should show that the individual has a medical prognosis that his or her life expectancy is six months or less if the illness runs its normal course. Here are some tips to accomplish this:

• Obtain any necessary information required for the medical record review, regardless of the location of the documentation. For instance, if General Inpatient Care (GIP) or Inpatient Respite Care (IRC) was provided in a Skilled Nursing Facility (SNF) or a hospital, the hospice should obtain the records from that facility.
• Make sure that the comprehensive assessment is included in the hospice beneficiary’s medical record. As stated in the Code of Federal Regulations (CFR)  (42 CFR 418.54 — Condition of participation: Initial and comprehensive assessment of the patient), “The hospice must conduct and document in writing a patient-specific comprehensive assessment that identifies the patient's need for hospice care and services, and the patient's need for physical, psychosocial, emotional, and spiritual care. This assessment includes all areas of hospice care related to the palliation and management of the terminal illness and related conditions.”
• Ensure the proper principle diagnosis is coded correctly. The principal diagnosis listed is the diagnosis most contributory to the terminal prognosis. Also, be sure to document comorbid and secondary conditions.
• Document level of care changes. The medical record must show the date, time and reason why the level of care changed. 
  • IRC — The medical record must show when the level of care was changed to respite care and the reason
  • GIP
    • Upon transfer to GIP level of care, documentation should include both:
      • A precipitating event (onset of uncontrolled symptoms or pain)
      • The interventions tried in the home that have been unsuccessful at controlling the symptoms
    • Supporting documentation for pain control may include:
      • Frequent evaluation by a doctor or nurse
      • Frequent medication adjustment
      • Intravenous (IV) medications that cannot be administered at home
      • Aggressive pain management
      • Complicated technical delivery of medication
    • Supporting documentation for symptom control may include:
      • Sudden deterioration requiring intensive nursing intervention
      • Uncontrolled nausea or vomiting
      • Pathological fractures
      • Open wounds requiring frequent skilled care
      • Unmanageable respiratory distress
      • New or worsening delirium
    • Continuous Home Care (CHC)
      • The supportive documentation should:
        • Show the beneficiary's condition warranting the interventions provided by the hospice staff at this higher level of care
        • Describe the beneficiary's response to care 
    • Although CHC is billed in 15-minute increments, the supportive documentation is not required to be every 15 minutes. Supportive documentation should be as frequent as necessary to support continued CHC and is suggested at least hourly.  

Resource: Medicare Benefit Policy Manual Chapter 9 — Coverage of Hospice Services Under Hospital Insurance (PDF).