Hospice Claims Under Review for 5011W

CGS announced a widespread probe review as a result of the analysis of errors related to the review for topic 5011W for claims selected for medical review between October 20, 2011, through March 31, 2012, CGS will be initiating a continuing widespread review for hospice providers.

The topic code for this review will be 5101T, and will select hospice claims for Debility, Alzheimer’s disease, and Chronic Airway Obstructions. Claims will be selected across the provider community billing these services that met the parameters of the edit. Once selected, the claims will be reviewed for medical necessity (e.g. compliance with CMS guidelines, contractor local coverage determinations (LCDs), correct billing and coding). Results of the widespread probe review are summarized below.

Most denials received by providers were related to the six-month terminal prognosis not being supported in the medical record documentation and for missing, incomplete or untimely certifications.

The top denial was 5PTER, documentation does not support the terminal prognosis. The Medicare Benefit Policy Manual, CMS Pub. 100-02, Ch. 9 (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c09.pdf), states an individual is eligible for the Medicare hospice benefit when that individual has a terminal illness with a life expectancy of six month or less if the terminal illness runs its normal course. The LCD for “Hospice – Determining Terminal Status” L32015, contains guidelines for hospice coverage for patients, and provides some documentation suggestions related to documenting terminal status. The patient’s appropriateness for the hospice benefit must be clearly supported in the medical record from admission and throughout the hospice care provided.

The other most common denial was 56900, which indicates that the medical records to support the services billed in response to the additional development request (ADR) were not submitted and/or the records were not received timely.

When a claim meets certain criteria for an edit set up the Fiscal Intermediary Standard System (FISS), an ADR is generated. The ADR message tells you what information is required, and providers have 30 days to respond and submit the requested information. If a provider does not respond, the entire claim is automatically denied on the 46th day with the denial reason code 56900. When an ADR is requested, the claim is moved to status/location S B6001.

Providers are encouraged to monitor the S B6001 status/location at least weekly to identify when an ADR has been requested. For additional information, please refer to the CMS Medicare Program Integrity Manual (Pub. 100-08), Ch. 3 at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/pim83c03.pdf

Be prepared for a review and medical necessity with your soon to be mailed PEPPER Report. The PEPPER Report will reflect how your hospice compares to other hospice providers on key metrics, such as length of stay and live discharge rates. The first reports will be mailed out to hospice providers in late August, according to CMS contractor TMF Quality Institute.