5CF01 - General Inpatient Services Not Reasonable and Necessary
The hospice services billed for general inpatient care days were not covered, as the submitted documentation did not support medical necessity. Therefore, the general inpatient care days were reduced to routine care days.
The hospice benefit allows for general inpatient care services if the hospital stay is reasonable and necessary. Documentation should include the following:
- Name of the contract facility in which the patient is receiving general inpatient care
- Explanation for admission to the inpatient facility
- Hospice interdisciplinary notes during the general inpatient stay and the physician’s discharge summary
- Documentation of the patient’s condition during the inpatient stay.
Hospitalization must be on a short-term basis and must be related to complications attributable to the terminal diagnosis which cannot be provided in other settings, such as pain control or symptom management.
How to prevent this denial
The documentation submitted must include the following:
- Need for pain control or symptom management that is not feasible in other settings
- Skilled care required when home support has broken down and it is no longer feasible to furnish needed care in the home setting
- Patient’s need for medication adjustment, observation or other stabilizing treatments which cannot be furnished in home
For further information on the above Medicare coverage issue, references include, but are not limited to the following: