Postpayment Service-Specific Probe Results for Hospice: General Inpatient Care for April through June 2021
Postpayment Service-Specific Probe Results for Hospice — General Inpatient Care (GIP) in Alabama, Arkansas, Florida, Georgia, Illinois, Indiana, Kentucky, Louisiana, Mississippi, New Mexico, North Carolina, Ohio, Oklahoma, South Carolina, Tennessee, Texas and Other States for April through June 2021
Palmetto GBA performed service-specific postpayment probe review on Hospice — General Inpatient Care (GIP). The results for the probe review for claims processed in Alabama, Arkansas, Florida, Georgia, Illinois, Indiana, Kentucky, Louisiana, Mississippi, New Mexico, North Carolina, Ohio, Oklahoma, South Carolina, Texas and other states for processing period April through June, 2021, are presented here.
Cumulative Results
A total of 1790 claims were reviewed with 397 of the claims either completely or partially denied, resulting in an overall claim denial rate of 22.18 percent. The total dollars reviewed was $13,890,735.96, of which $2,554,558.69 was denied, resulting in a charge denial rate of 18.39 percent. Overall, there were 66 auto-denied claims in the region. The top denial reasons were identified, and the number of occurrences based on dollars denied are:
Percent of Total Denials |
Denial Code |
Denial Description |
Number of Occurrences |
23.17% |
5CF91/5CF91 |
Hospice General Inpatient Reduction — Services Not Reasonable and Necessary |
92 |
20.65% |
5FNER/5CNER |
The Hospice Election Does Not Meet Statutory/Regulatory Requirements |
82 |
17.88% |
5FFH9/5CFH9 |
Physician Narrative Statement Not Present or Not Valid |
71 |
7.05% |
5FFH6/5CFH6 |
Initial Certification Not Timely |
28 |
5.29% |
5FNOE/5CNOE |
Partial Denial of Services Due to No Valid Election Statement Submitted |
21 |
Alabama Results
A total of 131 claims were reviewed in Alabama, with 19 of the claims either completely or partially denied. This resulted in a claim denial rate of 14.5 percent. The total dollars reviewed was $871,197.74, of which $81,832.62 was denied, resulting in a charge denial rate of 9.39 percent. The top denial reasons were identified, and the number of occurrences based on dollars denied are:
Percent of Total Denials |
Denial Code |
Denial Description |
Number of Occurrences |
26.32% |
5FFH9/5CFH9 |
Physician Narrative Statement Not Present or Not Valid |
5 |
21.05% |
5CF91/5CF91 |
Hospice General Inpatient Reduction — Services Not Reasonable and Necessary |
4 |
15.79% |
5FFH6/5CFH6 |
Initial Certification Not Timely |
3 |
10.53% |
5FFNP/5CFNP |
No Plan of Care Submitted |
2 |
5.26% |
5FNOE/5CNOE |
Partial Denial of Services Due to No Valid Election Statement Submitted |
1 |
Arkansas Results
A total of 113 claims were reviewed in Arkansas, with 17 of the claims either completely or partially denied. This resulted in a claim denial rate of 15.04 percent. The total dollars reviewed was $839,612.77, of which $71,953.37 was denied, resulting in a charge denial rate of 8.57 percent. The top denial reasons were identified, and the number of occurrences based on dollars denied are:
Percent of Total Denials |
Denial Code |
Denial Description |
Number of Occurrences |
29.41% |
5CF91/5CF91 |
General Inpatient Reduction — Services Not Reasonable and Necessary |
5 |
17.65% |
5FFH6/5CFH6 |
Initial Certification Not Timely |
3 |
11.76% |
5CF98 |
The Day of Discharge from An Inpatient Facility Is Paid at the Routine Home Care Rate; the Hospice Inpatient Level of Care Is Reduced to the Hospice Routine Care Rate for This Date |
2 |
5.88% |
5FNOE/5CNOE |
Partial Denial of Services due to No Valid Election Statement Submitted |
1 |
5.88% |
5FNER/5CNER |
The Hospice Election Does Not Meet Statutory/Regulatory Requirements |
1 |
Florida Results
A total of 221 claims were reviewed in Florida, with 33 of the claims either completely or partially denied. This resulted in a claim denial rate of 14.93 percent. The total dollars reviewed was $1,826,338.63, of which $174,992.47 was denied, resulting in a charge denial rate of 9.58 percent. The top denial reasons were identified, and the number of occurrences based on dollars denied are:
Percent of Total Denials |
Denial Code |
Denial Description |
Number of Occurrences |
30.30% |
5CF91/5CF91 |
Hospice General Inpatient Reduction — Services Not Reasonable and Necessary |
10 |
24.24% |
5FFNP/5CFNP |
No Plan of Care Submitted |
8 |
9.09% |
5FFIP/5CFIP |
Invalid Plan of Care Submitted |
3 |
9.09% |
5FFH9/5CFH9 |
Physician Narrative Statement Not Present or Not Valid |
3 |
6.06% |
5FFH6/5CFH6 |
Initial Certification Not Timely |
2 |
Georgia Results
A total of 389 claims were reviewed in Georgia, with 130 of the claims either completely or partially denied. This resulted in a claim denial rate of 33.42 percent. The total dollars reviewed was $3,165,535.91, of which $902,289.83 was denied, resulting in a charge denial rate of 28.50 percent. The top denial reasons were identified, and the number of occurrences based on dollars denied are:
Percent of Total Denials |
Denial Code |
Denial Description |
Number of Occurrences |
26.92% |
5CF91/5CF91 |
Hospice General Inpatient Reduction — Services Not Reasonable and Necessary |
35 |
20.00% |
5FFH9/5CFH9 |
Physician Narrative Statement Not Present or Not Valid |
26 |
19.23% |
5FNER/5CNER |
The Hospice Election Does Not Meet Statutory/Regulatory Requirements |
25 |
8.46% |
5FFTF/5CFTF |
Face-to-Face Encounter Requirements Not Met |
11 |
6.15% |
5FFH6/5CFH6 |
Initial Certification Not Timely |
8 |
Illinois Results
A total of 254 claims were reviewed in Illinois, with 55 of the claims either completely or partially denied.This resulted in a claim denial rate of 21.65 percent. The total dollars reviewed was $2,139,372.06, of which $443,567.84 was denied, resulting in a charge denial rate of 20.73 percent. The top denial reasons were identified, and the number of occurrences based on dollars denied are:
Percent of Total Denials |
Denial Code |
Denial Description |
Number of Occurrences |
40.00% |
5FFH9/5CFH9 |
Physician Narrative Statement Not Present or Not Valid |
22 |
16.36% |
5CF91/5CF91 |
Hospice General Inpatient Reduction — Services Not Reasonable and Necessary |
9 |
9.09% |
5FFH6/5CFH6 |
Initial Certification Not Timely |
5 |
7.27% |
5FFIP/5CFIP |
Invalid Plan of Care Submitted |
4 |
5.45% |
5CFH4 |
Initial Certification Not Signed |
3 |
Indiana Results
A total of 115 claims were reviewed in Indiana, with 20 of the claims either completely or partially denied. This resulted in a claim denial rate of 17.39 percent. The total dollars reviewed was $861,635.05, of which $124,671.35 was denied, resulting in a charge denial rate of 14.47 percent. The top denial reasons were identified, and the number of occurrences based on dollars denied are:
Percent of Total Denials |
Denial Code |
Denial Description |
Number of Occurrences |
50.0% |
5FNER/5CNER |
The Hospice Election Does Not Meet Statutory/Regulatory Requirements |
10 |
15.0% |
5CFH4 |
Initial Certification Not Signed |
3 |
10.0% |
5CF91/5CF91 |
Hospice General Inpatient Reduction — Services Not Reasonable and Necessary |
2 |
10.0% |
5FNOE/5CNOE |
No Valid Election Statement Submitted |
2 |
5.0% |
5FFH9/5CFH9 |
Physician Narrative Statement Not Present or Not Valid |
1 |
Kentucky Results
A total of 64 claims were reviewed in Kentucky, with 22 of the claims either completely or partially denied. This results in a claim denial rate of 34.38 percent. The total dollars reviewed was $475,657.65, of which $128,050.30 was denied, resulting in a charge denial rate of 26.92 percent. The top denial reasons were identified, and the number of occurrences based on dollars denied are:
Percent of Total Denials |
Denial Code |
Denial Description |
Number of Occurrences |
86.36% |
5FNER/5CNER |
The Hospice Election Does Not Meet Statutory/Regulatory Requirements |
19 |
9.09% |
5FFNP/5CFNP |
No Plan of Care Submitted |
2 |
4.55% |
5CFH4 |
Initial Certification Not Signed |
1 |
Louisiana Results
A total of 21 claims were reviewed in Louisiana, with eight of the claims either completely or partially denied. This results in a claim denial rate of 38.1 percent. The total dollars reviewed was $143,932.79, of which $43,130.00 was denied, resulting in a charge denial rate of 29.97 percent. The top denial reasons were identified, and the number of occurrences based on dollars denied are:
Percent of Total Denials |
Denial Code |
Denial Description |
Number of Occurrences |
50.0% |
5CF91/5CF91 |
Hospice General Inpatient Reduction — Services Not Reasonable and Necessary |
4 |
37.5% |
5FNER/5CNER |
The Hospice Election Does Not Meet Statutory/Regulatory Requirements |
3 |
12.5% |
5FFH9/5CFH9 |
Physician Narrative Statement Not Present or Not Valid |
1 |
Mississippi Results
A total of 13 claims were reviewed in Mississippi, with eight of the claims either completely or partially denied. This resulted in a claim denial rate of 61.54 percent. The total dollars reviewed was $117,344.44, of which $74,916.29 was denied, resulting in a charge denial rate of 63.84 percent. The top denial reasons were identified, and the number of occurrences based on dollars denied are:
Percent of Total Denials |
Denial Code |
Denial Description |
Number of Occurrences |
87.5% |
5FNER/5CNER |
The Hospice Election Does Not Meet Statutory/Regulatory Requirements |
7 |
12.5% |
5CFH4 |
Initial Certification Not Signed |
1 |
New Mexico Results
A total of one claim was reviewed in New Mexico, with no claims denied. This resulted in a claim denial rate of zero percent. The total dollars reviewed was $9,370.18 of which $0 was denied, resulting in a charge denial rate of zero percent.
North Carolina Results
A total of 41 claims were reviewed in North Carolina, with six of the claims either completely or partially denied. This resulted in a claim denial rate of 14.63 percent. The total dollars reviewed was $380,316.32, of which $24,573.52 was denied, resulting in a charge denial rate of 6.46 percent. The top denial reasons were identified, and the number of occurrences based on dollars denied are:
Percent of Total Denials |
Denial Code |
Denial Description |
Number of Occurrences |
33.33% |
5FFIP/5CFIP |
Invalid Plan of Care Submitted |
2 |
33.33% |
5CF91/5CF91 |
Hospice General Inpatient Reduction — Services Not Reasonable and Necessary |
2 |
16.67% |
5CF94 |
General Inpatient Days Reduced to Routine Care Days |
1 |
16.67% |
5CF98 |
The Day of Discharge from an Inpatient Facility Is Paid at the Routine Home Care Rate; the Hospice Inpatient Level of Care Is Reduced to the Hospice Routine Care Rate for This Date. |
1 |
Ohio Results
A total of 113 claims were reviewed in Ohio, with 26 of the claims either completely or partially denied. This resulted in a claim denial rate of 23.01 percent. The total dollars reviewed was $821,116.32, of which $164,829.00 was denied, resulting in a charge denial rate of 20.07 percent. The top denial reasons were identified, and the number of occurrences based on dollars denied are:
Percent of Total Denials |
Denial Code |
Denial Description |
Number of Occurrences |
30.77% |
5CF91/5CF91 |
Hospice General Inpatient Reduction — Services Not Reasonable and Necessary |
8 |
26.92% |
5FNOE/5CNOE |
No Valid Election Statement Submitted |
7 |
23.08% |
5FFH9/5CFH9 |
Physician Narrative Statement Not Present or Not Valid |
6 |
7.69% |
5FFH6/5CFH6 |
Initial Certification Not Timely |
2 |
7.69% |
5FNER/5CNER |
The Hospice Election Does Not Meet Statutory/Regulatory Requirements |
2 |
Oklahoma Results
A total of 49 claims were reviewed in Oklahoma, with seven of the claims either completely or partially denied. This resulted in a claim denial rate of 14.29 percent. The total dollars reviewed was $345,646.45, of which $47,165.54 was denied, resulting in a charge denial rate of 13.65 percent. The top denial reasons were identified, and the number of occurrences based on dollars denied are:
Percent of Total Denials |
Denial Code |
Denial Description |
Number of Occurrences |
28.57% |
5FFTF/5CFTF |
Face-to-Face Encounter Requirements Not Met |
2 |
14.29% |
5FFH9/5CFH9 |
Physician Narrative Statement Not Present or Not Valid |
1 |
14.29% |
5FNOE/5CNOE |
No Valid Election Statement Submitted |
1 |
14.29% |
5FFH6/5CFH6 |
Initial Certification Not Timely |
1 |
14.29% |
5FFIP/5CFIP |
Invalid Plan of Care Submitted |
1 |
Other States Results
A total of 17 claims were reviewed in other states, with seven of the claims either completely or partially denied. This resulted in a claim denial rate of 41.18 percent. The total dollars reviewed was $129,671.81, of which $31,961.98 was denied, resulting in a charge denial rate of 24.65 percent. The top denial reasons were identified, and the number of occurrences based on dollars denied are:
Percent of Total Denials |
Denial Code |
Denial Description |
Number of Occurrences |
42.86% |
5CF91/5CF91 |
Hospice General Inpatient Reduction — Services Not Reasonable and Necessary |
3 |
14.29% |
5FFIP/5CFIP |
Invalid Plan of Care Submitted |
1 |
14.29% |
5FFH9/5CFH9 |
Physician Narrative Statement Not Present or Not Valid |
1 |
14.29% |
5FNER/5CNER |
The Hospice Election Does Not Meet Statutory/Regulatory Requirements |
1 |
14.29% |
5CF98 |
The Day of Discharge from an Inpatient Facility Is Paid at the Routine Home Care Rate; the Hospice Inpatient Level of Care Is Reduced to the Hospice Routine Care Rate for This Date |
1 |
South Carolina Results
A total of 50 claims were reviewed in South Carolina, with 21 of the claims either completely or partially denied. This resulted in a claim denial rate of 42.00 percent. The total dollars reviewed was $392,857.39, of which $134,243.98 was denied, resulting in a charge denial rate of 34.17 percent. The top denial reasons were identified, and the number of occurrences based on dollars denied are:
Percent of Total Denials |
Denial Code |
Denial Description |
Number of Occurrences |
42.86% |
5FNER/5CNER |
The Hospice Election Does Not Meet Statutory/Regulatory Requirements |
9 |
19.05% |
5CF91/5CF91 |
Hospice General Inpatient Reduction — Services Not Reasonable and Necessary |
4 |
9.52% |
5FNOE/5CNOE |
No Valid Election Statement Submitted |
2 |
9.52% |
5FFH3/5CFH3 |
No Certification for Dates Billed |
2 |
9.52% |
5FFH6/5CFH6 |
Initial Certification Not Timely |
2 |
Tennessee Results
A total of 137 claims were reviewed in Tennessee, with nine of the claims either completely or partially denied. This resulted in a claim denial rate of 6.57 percent. The total dollars reviewed was $921,887.07, of which $42,611.06 was denied, resulting in a charge denial rate of 4.62 percent. The top denial reasons were identified, and the number of occurrences based on dollars denied are:
Percent of Total Denials |
Denial Code |
Denial Description |
Number of Occurrences |
66.67% |
5CF91/5CF91 |
Hospice General Inpatient Reduction — Services Not Reasonable and Necessary |
6 |
22.22% |
5FFH9/5CFH9 |
Physician Narrative Statement Not Present or Not Valid |
2 |
11.11% |
5FFTF/5CFTF |
Face-to-Face Encounter Requirements Not Met |
1 |
Texas Results
A total of 61 claims were reviewed in Texas, with nine of the claims either completely or partially denied. This resulted in a claim denial rate of 14.75 percent. The total dollars reviewed was $446,998.80, of which $63,769.54 was denied, resulting in a charge denial rate of 14.27 percent. The top denial reasons were identified, and the number of occurrences based on dollars denied are:
Percent of Total Denials |
Denial Code |
Denial Description |
Number of Occurrences |
22.22% |
5FFH6/5CFH6 |
Initial Certification Not Timely |
2 |
22.22% |
5FFH9/5CFH9 |
Physician Narrative Statement Not Present or Not Valid |
2 |
11.11% |
5FNOE/5CNOE |
No Valid Election Statement Submitted |
1 |
11.11% |
5FFTF/5CFTF |
Face-to-Face Encounter Requirements Not Met |
1 |
11.11% |
5FFNP/5CFNP |
No Plan of Care Submitted |
1 |
Denial Reasons and Prevention Recommendations
5CF91 — Hospice General Inpatient Reduction — Services Not Reasonable and Necessary
Reason for Denial
The hospice services billed for general inpatient care days were not covered, as submitted documentation did not support medical necessity. Therefore, the general inpatient care days were reduced to routine care days.
How to Avoid This Denial
The hospice benefit allows for general inpatient care services if the hospital stay is reasonable and necessary. Documentation should include the following:
- Name of the contract facility in which the patient is receiving general inpatient care
- Explanation for admission to the inpatient facility
- Hospice interdisciplinary notes during the general inpatient stay and the physician’s discharge summary
- Documentation of the patient’s condition during the inpatient stay
Hospitalization must be on a short-term basis and must be related to complications attributable to the terminal diagnosis such as pain control or symptom management which cannot be provided in other settings.
In order to avoid denials for this reason, the documentation submitted must include the following:
- Need for pain control or symptom management that is not feasible in other settings
- Skilled care required when home support has broken down and it is no longer feasible to furnish needed care in the home setting
- Patient’s need for medication adjustment, observation or other stabilizing treatments which cannot be furnished in home
More Information
- CMS Internet-Only Manual (IOM), 100-02, Medicare Benefit Policy Manual, Chapter 9, Section 40.1.5 (PDF, 453.26 KB)
- CMS Internet-Only Manual (IOM), 100-04, Medicare Claims Processing Manual, Chapter 11, Section 30.1 (PDF, 521.46 KB)
5FNER/5CNER — The Hospice Election Statement Does Not Meet Statutory/Regulatory Requirements
Reason for Denial
The claim has been fully or partially denied as the documentation submitted indicates that the statutory/regulatory requirements for the Hospice Election Statement were not met.
How to Avoid This Denial
A Medicare beneficiary must complete an election statement before the Hospice Medicare Benefit can begin.The election statement must include the following items of information:
- Identification of the hospice that will provide care to the individual
- The individual’s or representative’s (as applicable) acknowledgment that the individual has been given a full understanding of hospice care, particularly the palliative rather than curative nature of treatment
- The individual’s or representative’s (as applicable) acknowledgment that the individual understands that certain Medicare services are waived by the election
- The effective date of the election, which may be the first day of hospice care or a later date but may be no earlier than the date of the election statement. An individual may not designate an effective date that is retroactive.
- The individual’s designated attending physician (if any). Information identifying the attending physician recorded on the election statement should provide enough detail so that it is clear which physician or nurse practitioner (NP) was designated as the attending physician. This information should include, but is not limited to, the attending physician’s full name, office address, NPI number, and any other detailed information to clearly identify the attending physician.
- The individual’s acknowledgment that the designated attending physician was the individual’s or representative’s choice
- The signature of the individual or representative
More Information
- CMS Internet-Only Manual (IOM), 100-02, Medicare Benefit Policy Manual, Chapter 9, Sections 20.2.1.1 and 20.1.2 (PDF, 453.26 KB)
- Code of Federal Regulations, 42 CFR — Sections 418.24
5FFH9/5CFH9 — Physician Narrative Statement Not Present or Not Valid
Reason for Denial
The claim has been denied as the physician narrative statement is not present or not valid.
How to Avoid This Denial
- The physician must include a brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less as part of the certification and recertification forms, or as an addendum to the certification and recertification forms
- If the narrative is part of the certification or recertification form, then the narrative must be located immediately prior to the physician’s signature
- If the narrative exists as an addendum to the certification or recertification form, in addition to the physician’s signature on the certification or recertification form, the physician must also sign immediately following the narrative in the addendum
- The narrative shall include a statement under the physician signature attesting that by signing, the physician confirms that he/she composed the narrative based on his/her review of the patient’s medical record or, if applicable, his or her examination of the patient
- The narrative must reflect the patient’s individual circumstances and cannot contain check boxes or standard language used for all patients.
More Information
- Code of Federal Regulations, 42 CFR — Section 418.22
- CMS Internet-Only Manual (IOM), 100-02, Medicare Benefit Policy Manual, Chapter 9, Section 20 (PDF, 453.26 KB)
5FFH6/5CFH6 — Initial Certification Not Timely
Reason for Denial
The claim has been fully or partially denied, as the documentation submitted for review did not include an initial certification signed timely by the medical director and attending physician (if any).
How to Avoid This Denial
- For the first 90-day period of hospice coverage, the hospice must obtain, no later than two calendar days after hospice care is initiated (that is by the end of the third day), oral or written certification of the terminal illness by the medical director of the hospice or the physician member of the hospice interdisciplinary group and the beneficiary’s attending physician (if the beneficiary has an attending physician)
- Written certification must be on file in the hospice beneficiary’s record prior to submission of a claim to the Fiscal Intermediary
- If these requirements are not met, the payment begins with the day of certification
- The initial certification may be completed up to 15 days before hospice care is elected
- If the attending physician and the medical director are the same, the certification must clearly identify this information
More Information
- CMS Internet-Only Manual (IOM), 100-02, Medicare Benefit Policy Manual, Chapter 9, Sections 10 and 20.1 (PDF, 453.26 KB)
- Code of Federal Regulations, 42 CFR — Section 418.22
5FNOE/5CNOE — No Valid Election Statement Submitted
Reason for Denial
The services billed were not covered, as there was no signed notice of election statement included with the submitted documentation.
How to Avoid This Denial
A Medicare beneficiary must complete an election statement (Notice of Election, or NOE) before the Hospice Medicare Benefit (HMB) can begin. An individual, who meets the eligibility requirement of the 42 CFR Part 418.20, may file an election statement with a particular hospice. The representative for this individual may file if the beneficiary is physically or mentally incapacitated. The election statement must be signed no later than the first day for which the payment is claimed, and must also be signed if the beneficiary is re-electing the Hospice Medicare Benefit after a revocation or discharge from hospice.
The provider must submit a notice of election to the intermediary for every beneficiary who elects the hospice Medicare benefit. An individual (or his/her representative) must elect hospice care to receive it. Once the decision to receive hospice care is made, an election statement must be filed with a particular hospice.
All election statements must include the following information:
- Identification of the particular hospice that will provide care to the individual
- The individual’s or representative’s acknowledgement that the individual has been given a full understanding of hospice care, particularly the palliative rather than curative nature of hospice care
- The individual’s or representative’s acknowledgement that the individual understands that certain Medicare services, are waived by the election
- The individual’s designated attending physician (if any). Information identifying the attending physician recorded on the election statement should provide enough detail so that it is clear which physician or Nurse Practitioner (NP) was designated as the attending physician. This information should include, but is not limited to, the attending physician’s full name, office address, NPI number, or any other detailed information to clearly identify the attending physician.
- The individual’s acknowledgment that the designated attending physician was the individual’s or representative’s choice
- The effective date of the election, which may be the first day of hospice care or a later date but may be no earlier than the date of the election statement. An individual may not designate an effective date that is retroactive.
- The signature of the individual or representative
The duration of election will be considered to continue through the initial election period and through the subsequent election periods without a break in care as long as the individual remains in the care of a hospice and does not revoke the election under the provision of 42 CFR 418.28.
More Information
- CMS Internet-Only Manual (IOM), 100-02, Medicare Benefit Policy Manual, Chapter 9, Section 20.2 (PDF, 453.26 KB)
- 42 (CFR) Code of Federal Regulations — Sections 418.20, 418.24 and 418.28
5FFTF/5CFTF — Face-to-Face Encounter Requirements Not Met
Reason for Denial
The services billed were not covered because the documentation submitted for review did not include documentation of a face-to-face encounter.
How to Avoid This Denial
The face-to-face encounter must occur no more than 30 calendar days prior to the start of the third benefit period and no more than 30 calendar days prior to every subsequent benefit period thereafter.
Specific documentation related to face-to-face encounter requirements must be submitted for review. This includes, but is not limited to, the following:
- The hospice physician or nurse practitioner who performs the encounter must attest in writing that he or she had a face-to-face encounter with the patient, including the date of the encounter
- The attestation, its accompanying signature, and the date signed, must be separate and distinct section of, or an addendum to, the recertification form, must be clearly titled
- When a nurse practitioner or non-certifying hospice physician performs the encounter, the attestation must state that the clinical findings of that visit were provided to the certifying physician for use in determining whether the patient continues to have a life expectancy of six months or less, should the illness run its normal course
More Information
- Code of Federal Regulations, 42 CFR — Section 418.22
- CMS Internet-Only Manual (IOM), 100-02, Medicare Benefit Policy Manual, Chapter 9, Section 20.1 (PDF, 453.26 KB)
5FFNP/5CFNP — No Plan of Care
Reason for Denial
The claim has been fully or partially denied as documentation submitted for review did not include a plan of care for all or some of the dates billed.
Claims with dates of service beginning July 19, 2010, require that a valid plan of care (POC) be included as part of the medical review process according to Change Request 6982.
How to Avoid This Denial
- The hospice must submit a plan of care (POC) for dates of service billed when responding to ADR request
- All dates billed must be covered by a plan of care to be payable under the Medicare hospice benefit
- If more than one plan of care covers the dates of service in question, submit all the related plans of care for review
- The POC must contain certain information to be considered valid. This includes:
- Scope and frequency of services to meet the beneficiary’s/family’s needs
- Beneficiary-specific information, such as assessment of the beneficiary's needs, management of discomfort and symptom relief
- Services that are reasonable and necessary for the palliation and management of the beneficiary’s terminal illness and related conditions
- The plan of care must specify the hospice care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment
- All hospice care and services must follow an individualized written plan of care
- The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) must review, revise, and document the individualized plan as frequently as the patient's condition requires, but no less frequently than every 15 calendar days. A revised plan of care must include information from the patient's updated comprehensive assessment and must note the patient's progress toward outcomes and goals specified in the plan of care.
More Information
- Code of Federal Regulations, 42 CFR — Section 418.56 and 418.20
- CMS Internet-Only Manual (IOM), 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4 (PDF, 652.5 KB)
5CFH4 — Initial Certification Not Signed
Reason for Denial
The claim has been fully or partially denied as the documentation submitted for review did not include an initial certification signed by the medical director and attending physician (if any) to cover all or some of the dates of service billed.
How to Avoid This Denial
- In order to be eligible for hospice benefits under Medicare, the beneficiary must be certified as being terminally ill
- For the first 90-day period of hospice coverage, the hospice must obtain, no later than two calendar days after hospice care is initiated (that is, by the end of the third day), oral or written certification of the terminal illness by the medical director of the hospice or the physician member of the hospice interdisciplinary group and the beneficiary’s attending physician (if the beneficiary has an attending physician). If one physician is serving in both capacities, this must be clearly identified on the certification.
- Include certification with the medical records submitted for review, when responding to an ADR
- Ensure that the physician has signed the certification/recertification prior to submitting the claim to Medicare
More Information
- CMS Internet-Only Manual (IOM), 100-02, Medicare Benefit Policy Manual, Chapter 9, Section 20.1 (PDF, 453.26 KB)
- Code of Federal Regulations, 42 CFR — Sections 418.20 and 418.22
5FFIP/5CFIP — Invalid Plan of Care
Reason for Denial
The claim has been fully or partially denied as the documentation submitted for review did not include a valid plan of care for all or some of the dates billed.
For a beneficiary to receive hospice care covered by Medicare, a plan of care (POC) must be established before services are provided. The POC is developed from the initial assessment and comprehensive assessment and services provided must be consistent with the POC.
How to Avoid This Denial
The POC must contain certain information to be considered valid. This includes:
- Scope and frequency of services to meet the beneficiary's/family's needs
- Beneficiary-specific information, such as assessment of the beneficiary's needs, management of discomfort and symptom relief
- Services that are reasonable and necessary for the palliation and management of the beneficiary's terminal illness and related conditions
- The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) must review, revise, and document the individualized plan as frequently as the patient's condition requires, but no less frequently than every 15 calendar days. POC must include information from the patient's updated comprehensive assessment and must note the patient's progress toward outcomes and goals specified in the plan of care.
More Information
- Code of Federal Regulations, 42 CFR — Section 418.56 and 418.200
- CMS Internet-Only Manual (IOM), 100-02, Medicare Benefit Policy Manual, Chapter 9, Section 40 (PDF, 453.26 KB)
- CMS Internet-Only Manual (IOM), 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.4.1.1 (PDF, 652.5 KB)
5CF98 — The Day of Discharge from an Inpatient Facility Is Paid at the Routine Home Care Rate; the Hospice Inpatient Level of Care Is Reduced to the Hospice Routine Care Rate for this Date
Reason for Denial
The day of discharge from the Inpatient Level of Care is paid at the Routine Home Care rate.
How to Avoid This Denial
- Any day of which the beneficiary is in an inpatient approved facility for inpatient care, the appropriate inpatient rate (general or respite) is paid depending on the category of care furnished. The inpatient rate (general or respite) is paid for the date of admission and all subsequent inpatient days, except the day on which the patient is discharged. For the day of discharge, the appropriate home care rate is paid unless the patient dies as an inpatient.
More Information: Code of Federal Regulations, 42 CFR — Section 418.302.
5FFH3/5CFH3 — No Certification for Dates Billed
Reason for Denial
The claim has been fully or partially denied as documentation submitted for review did not include a certification covering all or some of the dates billed.
How to Avoid This Denial
- The hospice must obtain written certification of terminal illness for each benefit period
- All dates billed must be covered by a certification to be payable under the Medicare hospice benefit
- If more than one certification covers the dates of service in question, submit all the related certifications for review
More Information
- CMS Internet-Only Manual (IOM), 100-02, Medicare Benefit Policy Manual, Chapter 9, Sections 10 and 20.1 (PDF, 453.26 KB)
- Code of Federal Regulations, 42 CFR — Section 418.22
5CF94 — Hospice Inpatient Respite Care Reduced to Routine Care Days
Reason for Denial
The hospice services for Inpatient Respite Care were not covered, as submitted documentation did not indicate that respite care was provided. Therefore, the general inpatient care days were reduced to routine care days Inpatient Respite Care.
How to Avoid This Denial
Respite care is short-term inpatient care provided to the patient only when necessary to relieve the family members or other persons caring for the patient at home. Respite care may be provided only on an occasional basis and may not be reimbursed for more than five consecutive days at a time. It must be provided in a contracted Hospice Inpatient Unit such as a hospital, Skilled Nursing Facility (SNF), Nursing Home, or Intermediate Care Facility. Documentation of hospice care should include the necessity of respite care to include when it began and ended.
More Information
- CMS Internet-Only Manual (IOM), 100-02, Medicare Benefit Policy Manual, Chapter 9, Section 40.2.2 (PDF, 453.26 KB)
- CMS Internet-Only Manual (IOM), 100-04, Medicare Claims Processing Manual, Chapter 11, Section 30.1 (PDF, 521.46 KB)
5FF36/5CF36 — Documentation Submitted Does Not Support Prognosis of Six Months or Less
Reason for Denial
The claim has been fully or partially denied because the documentation submitted for review did not support prognosis of six months or less.
How to Avoid This Denial
- Ensure a legible signature is present on all documentation necessary to support six-month prognosis
- Submit documentation for review to provide clear evidence the beneficiary has a six-month or fewer prognosis which supports hospice appropriateness at the time the benefit is elected and continues to be hospice appropriate for the dates of service billed
- Palmetto GBA has a Local Coverage Determination (LCD) for some non-cancer diagnoses. Submit documentation which supports the coverage criteria outlined in the policy. LCDs may be viewed on the Palmetto GBA Web site at www.PalmettoGBA.com/JM Home Health and Hospice/Medical Policies/LCDs and Related Articles.
- If documenting weight loss to demonstrate a decline in condition, include how much weight was lost over what period of time, past and current nutritional status, current weight, and any related interventions
- Document any comorbidity, which may further support the terminal condition of the beneficiary and the continuing appropriateness of hospice care
More Information
- CMS Internet-Only Manual (IOM), 100-02, Medicare Benefit Policy Manual, Chapter 9, Section 40 (PDF, 453.26 KB)
- CMS Internet-Only Manual (IOM), 100-04, Medicare Claims Processing Manual, Chapter 11, Section 10 (PDF, 521.46 KB)
- Palmetto GBA Local Coverage Determinations (LCDs), which are available at LCDs, NCDs, and Coverage Articles
5FFH8/5CFH8 — No Prognosis Statement
Reason for Denial
The claim has been fully denied, as the certification submitted with the documentation for review did not contain a six-month or less prognosis statement.
How to Avoid This Denial
- In order to be eligible for the hospice benefit under Medicare, the patient must be certified as being terminally ill with a prognosis of six months or less
- Ensure that the physician certification contains a prognosis statement that is included in the documentation submitted for review
More Information
- CMS Internet-Only Manual (IOM), 100-02, Medicare Benefit Policy Manual, Chapter 9, Sections 10 and 20.1 (PDF, 453.26 KB)
- Code of Federal Regulations, 42 CFR — Section 418.22
5CF9U — Hospice GIP Reduction — Services Not Due To Terminal Illness
Reason for Denial
The hospice services for general inpatient care days were reduced to routine care days because the documentation submitted did not support the inpatient stay as being related to the terminal condition.
How to Avoid This Denial
The hospice benefit allows for general inpatient care services if the hospital stay is related to the patient’s terminal diagnosis. Documentation should include the following:
- The name of the contract facility in which the patient is receiving general inpatient care
- An explanation for admission to the inpatient facility
- Hospice interdisciplinary notes during the general inpatient stay
- The physician’s discharge summary
- Documentation of the patient’s condition during the inpatient stay
Hospitalization must be on a short-term basis and should relate to complications attributable to the terminal diagnosis such as pain control or symptom management, which cannot be provided in other settings.
More Information
- CMS Internet-Only Manual (IOM), 100-02, Medicare Benefit Policy Manual, Chapter 9, Section 40.1.5 (PDF, 453.26 KB)
- CMS Internet-Only Manual (IOM), 100-04, Medicare Claims Processing Manual, Chapter 11, Section 30.1 (PDF, 521.46 KB)
5FFH7/5CFH7 — Subsequent Certification Not Timely
Reason for Denial
The claim has been fully or partially denied as the documentation submitted for review did not include a certification that was signed and dated timely by the certifying physician.
How to Avoid This Denial
- Certifications for subsequent benefit periods must be obtained no later than two days after the beginning of the new benefit period. Only one physician’s signature is required on a subsequent certification.
- Verbal certification may be submitted; however, there must be documentation in the medical records to indicate the certification was obtained within the time frame indicated above
- Verbal certification must be followed by a written certification, signed and dated by the physician prior to billing Medicare for the hospice care
- If no verbal certification is present and the written certification is signed later than two days after the beginning of the benefit period, allowable days will begin with the date of the physician’s signature
- The subsequent certification may be completed up to 15 days prior to the start of the benefit period
More Information
- CMS Internet-Only Manual (IOM), 100-02, Medicare Benefit Policy Manual, Chapter 9, Section 20.1 (PDF, 453.26 KB)
- Code of Federal Regulations, 42 CFR — Section 418.22
5CF93 — Respite Care Days Reduced to Routine Care Days
Reason for Denial
The hospice services for respite care were reduced to routine care days because the documentation submitted did not support the level of care billed.
How to Avoid This Denial
Respite care is short-term inpatient care provided to the patient only when necessary to relieve the family members or other persons caring for the patient at home. Respite care may be provided only on an occasional basis and may not be reimbursed for more than five consecutive days at a time. It must be provided in a contracted Hospice Inpatient Unit such as a hospital, Skilled Nursing Facility (SNF), Nursing Home, or Intermediate Care Facility. Documentation of hospice care should include the necessity of respite care to include when it began and ended.
More Information
- CMS Internet-Only Manual (IOM), 100-02, Medicare Benefit Policy Manual, Chapter 9, Section 40.2.2 (PDF, 453.26 KB)
- CMS Internet-Only Manual (IOM), 100-04, Medicare Claims Processing Manual, Chapter 11, Section 30.1 (PDF, 521.46 KB)
5CF70 — Continuous Care Hours Not Documented
Reason for Denial
The continuous care hours were denied as the documentation submitted for review did not include documentation of services provided for these hours.
How to Avoid This Denial
Ensure documentation for all hours billed is submitted. Documentation submitted for review should illustrate the following:
- The services provided, hour by hour and day by day.
- The beneficiary’s medical condition; and
- All disciplines providing the continuous care
More Information
- CMS Internet-Only Manual (IOM), 100-02, Medicare Benefit Policy Manual, Chapter 9, Section 40.2.1 (PDF, 453.26 KB)
- CMS Internet-Only Manual (IOM), 100-04, Medicare Claims Processing Manual, Chapter 11, Section 30.1 (PDF, 521.46 KB)
5TH99 — Billing Error
Reason for Denial
The services billed were not covered because the charges were billed in error.
How to Avoid This Denial
- Ensure accuracy of billing prior to submitting the claim(s) to Medicare
- Submit a corrected UB92 with an 817 or 827 bill type when billing errors are discovered by the hospice agency. If the claim has been selected for medical review, submit the hardcopy corrected UB92 with the records to Palmetto GBA.
More Information
- CMS Internet-Only Manual (IOM), 100-04, Medicare Claims Processing Manual, Chapter 11, Section 30.3 (PDF, 521.46 KB)
The Next Steps
The service-specific postpay medical review edits for Hospice — General Inpatient Care (GIP) — in Alabama, Arkansas, Florida, Georgia, Illinois, Indiana, Kentucky, Louisiana, Mississippi, New Mexico, North Carolina, Ohio, Oklahoma, South Carolina, Tennessee, Texas and other states will be continued based on moderate charge denial rates and medium to high impact severity errors. If significant billing aberrancies are identified, provider-specific review may be initiated.
If you are dissatisfied with a claim determination you have the right to request an appeal. Palmetto GBA encourages you to review the documentation originally submitted, and if you believe you have additional supporting documentation you may include this information with your appeal. For more information related to the appeals process please refer to the JM HH Pre-Claim Review Submission Request form (PDF, 1.02 MB). Questions regarding this medical review can be directed to the Palmetto GBA Provider Contact Center at 855–696–0705.