5CF91 - Hospice GIP Reduction - Services Not Reasonable/Necessary

The hospice services billed for general inpatient care days were not covered, as 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 such as pain control or symptom management which cannot be provided in other settings.

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:

• CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Chapter 9, Section 40.1.5
• CMS Manual System, Pub 100-04, Medicare Claims Processing Manual, Chapter 11, Section 30.1