Hospices Face Challenges in Determining Unrelated Conditions

Hospices often encounter difficulties when it comes to documenting which services are directly related to the patient’s terminal diagnosis as opposed to a comorbidity. Strategies for hospice providers to completing complete and accurate documentation include close examination of a patient’s health history and maintaining detailed records of patient care plans and medications needs.

“It is a very high burden of proof that hospices have to show conditions and comorbidities that are not related,” said Carol Javens, implementation manager for Dallas, Texas-based technology firm Axxess. “The bigger challenge is determining the unrelated business and finding the diagnosis that’s most contributory to the terminal prognosis of the individual. A lot of people have multiple major medical issues going on. It’s up to the hospice physician to put together the story, looking at the full picture of the patient as to what is the terminal diagnosis, and is the patient eligible for hospice services.”

With experience as a hospice nurse and knowledge in hospice education and compliance, Javens sat down with Hospice News this week during a webinar in collaboration to discuss hospice service documentation challenges and how end-of-life care providers can better navigate through the intricacies of relatedness.


Issues of documentation relatedness drew increased recent attention with changes to the hospice election statement under the Medicare benefit.

“A big trigger of why everyone’s talking about relatedness right now is the addendum to the [hospice] election that started last week,” said Javens. “Medicare patients admitted on or after October 1 will have the option to request an election statement addendum explaining why certain treatments and diagnoses are not covered under the hospice Medicare benefit.”

Effective October 1, 2020, hospices must provide Medicare beneficiaries with a written statement called a “Patient Notification of Hospice Non-Covered Items, Services, and Drugs” detailing the conditions, items, services or drugs that are determined to be unrelated to their terminal illness and conditions and not covered by the hospice benefit. All patients admitted on or before the effective date have the option to request the notice in writing upon electing the Medicare Hospice Benefit. Hospices must issue the written addendum within 72 hours or three days of a request made by the beneficiary, their representative, a non-hospice provider or a medical contractor.


Hospices have also increased focus on documentation relatedness in response to increased regulatory scrutiny from federal agencies. Fraudulent insurance billing and payment errors were among the top concerns identified in two major reports issued by the U.S. Department of Health and Human Services Office of Inspector General (OIG).

The OIG called for increased oversight from the U.S. Centers for Medicare & Medicaid Services (CMS) regarding beneficiary costs of services, medications and care related to hospice. The reports led to changes in increased documentation requirements that have posed challenges for many hospices nationwide.

“Looking at the secondary and comorbid conditions, diagnoses and symptoms and getting as much history as possible at admission or soon as possible after is key,” Javens told Hospice News. “Sometimes we admit patients urgently and we don’t have time to get every single record because they’re in symptom distress, but as soon as possible get the attending physician records, get the patient’s hospital discharge summary, history and physical. The hospice organization, specifically the primary hospice attending physician, needs to review each secondary and comorbid condition — no matter what your primary diagnosis is — to determine if any of these conditions are contributing to the six-month prognosis. It’s going to help make the prognosis decision part of why you feel that this person is going to have six months or less.”

According to Javens, hospice providers need to document all secondary and comorbid conditions in a patient’s record and submit on insurance claims, regardless of relatedness to their terminal illness, as they can impact a patient’s condition. Renal disease, liver disease, chronic obstructive pulmonary disease, chronic heart failure, diabetes mellitus, HIV or AIDS, cancer, Lupus and rheumatoid arthritis were among the contributing comorbidities that Medicare has identified as significantly impacting a patient’s terminal prognosis.

Determining medication and treatment relatedness as another challenge. Prescribing and de-prescribing medications as appropriate to end-of-life care is among the issues in identifying what is and is not covered under the Medicare Hospice Benefit.

“Looking at what is related and not related, what medications should be covered and not be covered, is not a one time decision because these medications risk versus benefit analysis can change as the patient declines,” Javens said. “Have your pharmacist review these medications, especially if you have a contract with a pharmacy benefit manager. Get that pharmacy consult and see what are some of the things that you can be reducing, eliminating or changing for the patient to have them be as safe as possible, as well as cost effective as possible. What is also really important to look at is your medications related to conditions that do not affect the prognosis, but are needed to maintain equilibrium.”

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