Targeted Probe and Educate (TPE) is underway for Hospice Agencies. HPS is seeing many ADR denials with agencies moving to round 2 and 3 of TPE from both CGS and NGS. Palmetto GBA is expected to begin TPE for hospice in September 2018.

Both NGS and CGS have issued a high percentage of hospice denials that are focused around the six-month terminal prognosis.

The CGS website reports 73% of claims reviewed from April-June 2018 were denied because the submitted documentation did not support a terminal prognosis of 6 months or less.

The NGS website reports issues with documentation not supporting terminal prognosis continues to be the reason why providers will be moving onto round two and three of targeted probe and educate.

What does this mean? The reviewer is not finding enough documentation regarding the patient’s current condition to support a six month or less prognosis. It is imperative the documentation submitted shows the patient’s terminal status, for the claim dates being reviewed, to avoid denials.

Hospices are seeing denials for the six-month prognosis in recertification benefit periods, according to the medical review denial reasons, because documentation did not demonstrate the patient’s current condition and/or an acute change in the patient’s medical condition to support a life expectancy of six months or less.

How can the denial be avoided? Hospices need to continue to focus on documentation to support disease progression of the terminal illness and related conditions to meet hospice eligibility. To avoid ADR denials the hospice documentation should include:

  • Support for both non-reversible and persistent symptoms of disease progression
  • Any change in the patient’s condition that supports ongoing disease progression
  • Objective clinical findings to support the applicable Local Coverage Determination (LCD)*
  • Specific patient findings for symptoms of disease progression for weight loss, decrease in appetite and sleeping patterns must be documented when used to support prognosis.

ADR denials are also being seen in the following areas:

  • Certification of Terminal Illness (CTI) missing or untimely.
  • Verbal/Written certification are not obtained within 2 calendar days, after the first day of the benefit period.
  • The Face to Face requirement not met for claims within the third and subsequent benefit periods.

When preparing an ADR response:

  • Consider including documentation prior to and following the claim dates being reviewed that support the terminal prognosis.
  • Be sure to include the certification documentation for the initial benefit period and if the dates under review include 2 benefit periods, you must send the certification documentation for both.
  • A clinical review of the documentation should be completed prior to submitting the ADR response.

Our targeted probe and educate consulting team would be happy to assist with reviewing charts that have been selected for ADR reviews or answer any additional questions you may have. We are currently assisting agencies across the country through TPE.