Responding to a Hospice Additional Documentation Request

Published 06/08/2018

Responding to a Hospice Additional Documentation Request

The following list is a recommendation for what to include when responding to an Additional Documentation Request (ADR):

  • A valid signed notice of election
  • Include a statement if no attending physician or if the hospice medical director is the attending physician
  • Physician’s certification to cover the dates of services billed. If more than one certification covers the dates of service in question, please submit all certifications for the dates of service billed. The certification must include a statement of prognosis of six months or less. If this statement is not included on every page of the certification, please submit the page that has this statement and number the pages of the certification (e.g., Page 1 of 3). The certification includes the physician narrative for the first and second benefit period and face to face encounter documentation for the third and subsequent benefit periods. The attestation is part of the narrative.
  • Plan of care/interdisciplinary notes that covers the dates of service billed (may need to submit Interdisciplinary note from the month prior in order to cover the beginning dates of service billed)
  • If the beneficiary has expired, please submit information regarding date and cause of death
  • Please submit any documentation that would support the patient’s hospice Medicare benefit appropriateness and medical necessity of level of care billed
    • If general inpatient care is provided, please submit the physician’s orders/updated plan of care for when this care began
    • If continuous care is billed, include notes for all hours that care is rendered, including when continuous care began and ended
    • If respite is billed, include reason for respite
  • Include documentation to support coverage under the Local Coverage Determinations (LCDs) for patients with non-cancerous diagnoses
    • Include documentation showing structural/functional impairments to support terminality
    • Document all pertinent diagnoses that relate to the patient’s terminal condition and hospice appropriateness
    • Documentation related to comorbidities or change in the patient’s medical condition is considered an important part of the review process
  • Include any additional information that distinguishes the terminality of this beneficiary from others with the same diagnosis who are not terminal. Include documentation from all members of the interdisciplinary team members including the social worker, chaplain or volunteers. Non-nursing documentation can help give the medical review team additional insight into the patient’s medical condition. For example, if weight loss is documented, include the current weight and previous weight.
  • Frequent assessments of the patient’s condition and hospice appropriateness should be included in the submitted documentation. Ensure the submitted documentation distinguishes between exacerbation with stabilization and exacerbation with deterioration. If the documentation for the dates of service in question does not paint a clear picture of the patient’s hospice appropriateness, you may also submit documentation for the month(s) prior to or subsequent to the dates of service requested.
  • If responding to multiple requests in a single envelope, ensure each response is clearly separated. If responding to more than one date of service on the same beneficiary, send a response for each request separately. Include a manifest or list identifying each ADR response sent.
  • Attach a copy of the original ADR with the original ADR barcoded letter to each individual ADR response
  • Use one staple or elastic band per record to attach the documentation and ADR together. Do not use paper clips, as they can become dislodged.
  • Do not punch holes in medical records, as this may obscure valuable information
  • Return the medical records to the appropriate address listed below or on the ADR

    For Postal Delivery Please Use:
    Medicare Part A Medical Review
    Mail Code: AG-230
    P.O. Box 100238
    Columbia, SC 29202-3238
  • Do not include any correspondence other than ADR responses to the medical review department in your envelope
  • If sending additional documentation after you have already responded to the ADR, submit a copy of the ADR along with a cover letter. Note: We encourage you to gather all information and submit at one time. Sending subsequent documentation separately increases the chance that the medical review department may not receive it prior to a payment decision being made.
  • If billing corrections are needed, submit a paper copy UB04 with a XX7 bill type along with your medical records
  • Unfortunately, we are not able to accept packages on a C.O.D. basis. Please make sure that you have sent packages with the shipping prepaid.
  • If you send a CD or DVD for medical review or appeal documentation, please send the entire document (including documents with multiple pages) in a PDF or TIFF format
    • Please don't create a PDF or TIFF file of each page. One PDF or TIFF file per record is acceptable.
    • No password is required; however, if you do use a password, please include the tracking number of the documents/disk to ensure we are able to link the CD with the password
  • Records may be faxed to (803) 699–2436
  • Records may be sent via esMD (Electronic Submission of Medical Documentation System)

The Palmetto GBA Medical Review Department developed a Responding to a Hospice Additional Documentation Request (ADR) checklist. Please complete this checklist and include it when responding to an ADR. To access this checklist, select the PDF document below.

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