Advance directive review not conducted (Updated for 2026)

Common Causes for HOS28

Denials with code HOS28 typically happen for the following specific reasons:

• Failure to document the discussion, status, or existence of an advance directive within the patient's medical record during admission or an eligible encounter.
• Submitting claims for Advance Care Planning codes (CPT 99497 or 99498) without supporting clinical documentation demonstrating that a review actually took place.
• Non-compliance with Medicare Conditions of Participation (CoPs) which mandate that providers inform patients of their right to establish advance directives and document whether they have done so.
• Omitting the mandatory provider signature, date, or time spent discussing the advance directives during the face-to-face encounter.

How to Prevent HOS28 Denials

To avoid receiving this denial in the future, implement these specific checks:

• Implement clinical templates and hard stops in the Electronic Health Record (EHR) that force providers to document the status of the patient's advance directive during intake or annual wellness visits.
• Conduct routine staff training on CMS billing and documentation requirements for Advance Care Planning (ACP) services to ensure all regulatory elements are captured.
• Establish an automated workflow to verify, upload, and flag existing advance directives in the patient chart at the point of admission.
• Perform periodic internal audits on hospice and palliative care claims to ensure the advance directive review is completed and signed off before billing.

Appeal Letter Template for HOS28

If you believe this claim was denied incorrectly, you can use the following template to submit an appeal.

[Your Practice Header]
[Date]

[Payer Name]
[Appeals Department Address]

RE: Appeal for Claim [Claim Number]
Patient: [Patient Name]
ID: [Patient ID]
Date of Service: [Date]
Denial Code: HOS28 - Advance directive review not conducted

Dear Appeals Department,

I am writing to appeal the denial of the above-referenced claim, which was denied with code HOS28: "Advance directive review not conducted".

We are appealing the denial of this claim associated with code HOS28 (Advance directive review not conducted). Upon clinical review of the patient's medical records for the encounter on the specified date of service, we have verified that a comprehensive advance directive review was successfully conducted, documented, and signed by the rendering provider in strict alignment with CMS Conditions of Participation and AMA guidelines. The attached clinical documentation clearly shows that the provider inquired about the patient's advance directive status, reviewed their end-of-life care preferences, and updated the medical record accordingly. As all regulatory and documentation requirements for this service have been fully met, we respectfully request that this denial be overturned and the claim be processed for immediate payment.

Attached please find:
1. A copy of the original claim.
2. The relevant medical records supporting the service.
3. [Any other supporting documents].

We respectfully request that you reprocess this claim for payment.

Sincerely,

[Your Name]
[Title]
[Practice Name]