Ind. IHCP Hospice Services Provider Reference Module, Section 5, Criteria for Adequate Medical Documentation

Since the implementation of the IHCP hospice benefit, each PA-UM contractor has notified the state of

concerns with hospice providers’ medical documentation. The Family and Social Services Administration

(FSSA) was advised by all IHCP PA-UM contractors that hospice providers were submitting medical

documentation for IHCP hospice authorization that was either incomplete in the required forms or was

insufficient for the hospice analyst to confirm the ongoing terminal condition of the patient. Because all

hospice providers are required to be Medicare-certified before the IHCP can enroll the hospice agency as

an IHCP hospice provider, each hospice agency must ensure that the medical documentation submitted to

the IHCP PA-UM contractor for hospice authorization meets Medicare hospice conditions of participation.

When entering the third hospice benefit period of 60 continuous days, hospice providers must be as specific

as possible about the medical documentation that supports the appropriateness of the individual’s hospice

care. If the hospice analyst determines that the information is insufficient to process the request, the hospice

analyst must request that the provider submit documentation required to process the request. The IHCP can

request additional information when the documentation submitted by a provider i s insufficient.

Medical documentation guidelines for hospice providers include the following:

• The individual must have a terminal prognosis as well as physician certification that meets the

Medicare hospice conditions of participation (see the Hospice Authorization Process section of this

document for a description of the certification requirements).

• The clinical evidence must support the terminal diagnosis at the time of the initial certification and

at the time of each subsequent certification and must describe the patient’s condition.

• Documentation must illustrate why the patient is considered terminal and not chronic. History is

helpful when it provides clarification as to why the current documentation reflects only a chronic

condition.

• Each patient’s documentation must be specific to the individual and include any additional

documentation that distinguishes this patient from other patients with the same disease who may be

chronic but are not terminal.

• For each hospice benefit period, the interdisciplinary team must assess the patient’s condition and

hospice appropriateness, and the documentation must distinguish between exacerbation and

stabilization, as well as between exacerbation and deterioration.

• The documentation must include the most specific and most terminal International Classification of

Diseases (ICD) diagnosis code appropriate to the patient.

• The documentation must specify why any medication, treatments or services that could be

considered aggressive are considered necessary for the patient’s palliative treatment.

• The patient’s decline must be documented in detail.

• Providers must show how the systems of the patient’s body are in a terminal condition.

The Centers for Medicare & Medicaid Services (CMS) and the Office of Inspector General (OIG)

have expressed ongoing concerns regarding inadequate review of a hospice patient’s status during the

interdisciplinary team meetings for the third hospice benefit periods of 60 days. This inadequate review has

resulted in the hospices receiving improper reimbursement for services provided to a patient who fails to

continue to be eligible for the Medicare hospice benefit. Failure to document hospice care appropriateness,

justifying reimbursement for Medicare and Medicaid, can result in recoupment of the appropriate

hospice per diem by Medicare auditors for dually eligible hospice members, and recoupment from the

IHCP for payment of the IHCP per diem for Medicaid-only hospice members.

Note: 405 IAC 5-34-5 requires that a hospice physician or a hospice nurse practitioner

must have a face-to-face encounter with a member receiving hospice care to

determine continued eligibility for hospice care for the member’s third benefit period

and every benefit period thereafter. The face-to-face encounter must occur not more

than 30 calendar days before recertification of the third benefit period and of every

subsequent benefit period.

When approval for a benefit period is granted, a hospice provider can manage a patient’s care at the four

levels of service, according to the medical needs determined by the interdisciplinary team and the

requirements of the patient, the patient’s family or the primary care provider.

Note: Changes in levels of service do not require hospice authorization as long as these

levels are rendered within a hospice benefit period that the IHCP PA-UM contractor

has previously authorized.