This post is for hospice providers preparing to submit Medicare claims for October 2014. All hospice providers should be aware of the invalid principal diagnosis codes identified by CMS in Change Request 8877 CR 8877 was accompanied by a Medicare Learning Network article (MM8877) explaining why some hospice organizations will have claims returned to them for correction of the principal diagnosis, while others will not.  Hospice organizations with returned claims will have to expend additional time and effort to correct the claims, but even those organizations with no claims returned should read this post.


Hospice organizations receiving returned claims for “a more definitive hospice diagnosis based on ICD-9-CM/ICD-10-CM Coding Guidelines” will need to analyze and correct their processes and procedures in order to prevent additional re-work next month. Hospice organizations that do not have claims returned due to invalid principal diagnoses, should nonetheless be interested in knowing if they’ve implemented the most efficient solution. By that I mean, did your organization achieve their performance manually (by visually inspecting every claim prior to billing), by forcing compliance (not permitting invalid codes to be used at a billing system level), or by re-engineering your organizations process flows to ensure that the admitting and on-call nurses have the necessary support to “get it right the first time” for newly admitted patients?


Some may ask, why should it matter as long as the invalid codes are not billed? Most hospice organizations rely on their admitting/on-call nurses to capture the information necessary to inform the certification process. Re-engineering your organizations process flows will not only help the referral, admissions and certification processes, but will also improve the information available to the IDG for representing the “terminal illness” and “related conditions” in your healthcare records following the admission. Do your current referral, admission, and certification processes help your admitting and on-call nurses get it right the first time?





2 Responses to Invalid Hospice Principal Diagnoses – Is Your Organization getting it Right the First Time?

  1. Ronald Hirsch, MD says:

    An important issue; thanks for the reminder but I was unaware that nurses can make a diagnosis or refer patients to hospice. Efforts should be directed at the physician who is caring for the patient.

  2. Harry Feliciano says:

    Dr. Hirsch,

    Thank you for your comment. While nurses do not make a diagnosis, refer or certify hospice patients, they do provide hospice physicians and other Interdisciplinary Group (IDG) members with critical information so that the diagnosis most contributory to the terminal prognosis is listed as the principal diagnosis on Medicare hospice claims. Palmetto GBA has engaged in a collaboration with hospice providers (called the Hospice Organizational Process Improvement Coaching Project) to describe their critical processes. Based on this collaboration we know that the current organizational hospice workflows, especially how the admitting/on-call nurses record and communicate their first-hand observations with the certifying hospice physicians, influence the selection of the principal diagnosis. By going “upstream” in the process flow to improve the effectiveness and efficiency of communication between the admitting/on-call nurses and the certifying physician our collaboration’s goal is to reduce errors and eliminate waste.


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