Top Reasons for ADRs in Hospice and How to Prevent Them with Better Documentation

In today’s regulatory environment, hospice providers are under increasing scrutiny from Medicare and other oversight bodies. One of the most frequent—and feared—regulatory events a hospice agency may face is the Additional Documentation Request (ADR). Receiving an ADR does not necessarily imply wrongdoing, but it does signal that Medicare contractors need more information to justify payment. Unfortunately, poor or inconsistent documentation can result in delayed payments, denials, or even targeted audits.

To help hospice providers better understand and navigate this process, this article explores the top reasons ADRs occur and how proactive, robust documentation practices can dramatically reduce the likelihood of denials.

What Is an ADR in Hospice?

An Additional Documentation Request (ADR) is issued when a Medicare Administrative Contractor (MAC), like NGS or Palmetto GBA, requires further clinical or administrative documentation to support a claim for payment. The ADR is typically triggered during pre- or post-payment review processes.

When you receive an ADR, you have a limited timeframe—usually 45 calendar days—to respond with the requested documentation. Failure to do so can result in an automatic denial.

Top Reasons for Hospice ADRs

Understanding the most common triggers for ADRs is essential to preventing them. Based on MAC guidance and industry audit trends, here are the top reasons:

1. Insufficient Documentation of Terminal Prognosis

Medicare requires a life expectancy of six months or less if the terminal illness runs its normal course. The certifying physician's narrative (§418.22(b)) must clearly support this prognosis. Vague statements or boilerplate language can trigger a denial.

Prevention Tip: Ensure the physician narrative is individualized, specific, and clearly supports the six-month prognosis using clinical indicators like weight loss, PPS scores, disease progression, or comorbidities.

2. Inadequate Face-to-Face (F2F) Encounter Documentation

Medicare requires a Face-to-Face encounter for recertification of hospice eligibility starting at the third benefit period (i.e., day 180 and beyond). If the encounter is missing, late, or lacks clear documentation, it is grounds for automatic denial.

Prevention Tip: Always document the exact date, the clinician who conducted the visit, and ensure the encounter supports continued hospice eligibility.

3. Missing or Incomplete Plan of Care (POC)

The POC must be established, reviewed, and updated every 15 days (§418.56). All hospice services must be provided according to this individualized care plan.

Prevention Tip: Use a comprehensive interdisciplinary team (IDT) template and ensure timely updates based on the patient's condition changes.

4. Lack of Continuous Care or Crisis Documentation

Continuous home care or general inpatient hospice care claims must include clear documentation of symptom crisis, need for skilled nursing, and appropriateness per §418.204.

Prevention Tip: Clearly indicate why care exceeded routine level, with detailed clinical notes to support this level of intensity.

5. Improper Documentation of Bereavement and Spiritual Services

While not billable, these are required elements of the comprehensive hospice program under §418.64. Missing assessments or notes may raise red flags in audits.

Prevention Tip: Include initial bereavement risk assessments, regular contact logs, and any spiritual or psychosocial interventions offered.

6. No Documentation of Decline

When patients stabilize or show improvement, yet remain on hospice without updated eligibility justification, this can raise audit concerns. MACs look for documentation of decline over time.

Prevention Tip: Maintain consistent clinical documentation showing the trajectory of decline, functional losses, and ongoing symptoms—even if subtle.

Best Practices to Prevent ADRs Through Strong Documentation

1. Train Your Team – Ensure all staff (nurses, chaplains, social workers) understand what needs to be documented, why, and how often.

2. Standardize Documentation – Use structured templates that align with CMS Conditions of Participation (CoPs).

3. Conduct Regular Chart Audits – At least monthly, audit random records internally or through a third party.

4. Implement a Pre-Billing Review Process – Scrutinize all claims before submission to catch errors or omissions early.

5. Document Interdisciplinary Collaboration – Reflect IDG meetings and coordinated care in the record to show compliance with §418.56.

CMS Conditions of Participation Supporting Documentation Requirements

• §418.22 – Certification of Terminal Illness

• §418.54 – Initial and Comprehensive Assessment

• §418.56 – Interdisciplinary Group, Care Planning

• §418.64 – Core Services (includes nursing, medical social, and counseling services)

• §418.100 – Organizational Environment and Quality Assurance

Being familiar with these CoPs ensures you're building documentation practices that CMS expects to see during audits or surveys.

Conclusion: Be Proactive, Not Reactive

The cost of poor documentation goes beyond denials—it risks noncompliance, tarnished reputations, and cash flow problems. By understanding the common reasons ADRs occur and implementing rigorous documentation standards, your hospice agency can stay ahead of audits and maintain operational integrity.

Need Help? Turn to SummitRidge

At SummitRidge, we specialize in helping hospice agencies succeed through expert documentation systems, CMS survey support, ADR defense, and tailored compliance solutions. Our suite of tools and consulting services ensures your agency is always survey-ready and operationally sound.

Let us help you build a strong documentation foundation—before the ADR arrives.