5CF36, 5FF36: Not Hospice Appropriate

Published 05/10/2022

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

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