Hospice Care: Extended Length of Stay: Medical Necessity and Documentation Requirements

In December 2023, Performant, the designated Recovery Audit Contractor (RAC) for the Centers for Medicare and Medicaid Services (CMS), introduced a new issue, Issue 0221 – Hospice Care: Extended Length of Stay: Medical Necessity and Documentation Requirements, to its approved list.  This newly added issue centers on evaluating the “Extended Length of Stay” to verify medical necessity for hospice care and the corresponding documentation requirements.  Performant will scrutinize all four levels of hospice care – Routine Home Care, Continuous Home Care, Inpatient Respite Care, and General Inpatient Care (GIP).

Performant reserves the right to review records pertaining to extended hospice stays for claims dating up to three years prior to the Additional Documentation Request (ADR) date.  Although CMS generally defines an extended length of stay as exceeding 181 days, there is some ambiguity regarding this definition.

This hospice-focused initiative follows an earlier approved issue in 2023 with Issue 0212 – Hospice General Inpatient Care: Medical Necessity and Documentation Requirements.  That review focuses on GIP claims that do not align with the stipulated coverage or medical necessity for GIP.  Claims that do fail the review will be reclassified to Routine Home Care 0651, resulting in overpayments.  Similar to extended length of stay audits, Performant can request records for GIP claims within three years of the ADR date.

Notably, while only one issue has been approved for home health, the RAC’s emphasis on hospice underscores CMS’s overarching focus on hospice program integrity.  It is essential to be aware that Performant serves as CMS’s nationwide contractor for hospice, home health, and DMEPOS, reinforcing its pivotal role in ensuring the integrity and compliance of critical healthcare programs.