Postpayment Service-Specific Probe Results for Hospice (General Inpatient Care) for October through December 2020

Palmetto GBA performed service-specific postpayment probe review on hospice (general inpatient care). This edit was set in Alabama, Arkansas, Florida, Georgia, Illinois, Indiana, Kentucky, Louisiana, Mississippi, New Mexico, North Carolina, Ohio, Oklahoma, South Carolina, Tennessee, Texas, and Other States. The results for the probe review for claims processed in Alabama, Arkansas, Kentucky, and Louisiana, for processing period October through December 2020.

Cumulative Results
A total of 14 claims were reviewed in Alabama, Arkansas, Kentucky, and Louisiana with six of the claims either completely or partially denied: resulting in an overall claim denial rate of 42.86 percent. The total dollars reviewed was $126,341.15 of which $46,093.74 was denied, resulting in a charge denial rate of 36.48 percent. Overall, there were no auto denied claims in the region.

Alabama Results
A total of six claims were reviewed in Alabama, with one of the claims either completely or partially denied. This resulted in a claim denial rate of 16.67 percent. The total dollars reviewed was $46,399.07 of which $8,530.00 was denied, resulting in a charge denial rate of 18.38 percent. The top denial reasons were identified based on dollars denied.

In order to provide more specific information, regarding the denial reasons identified above, a second level of detail was obtained during Medical Review. Each claim that was reviewed may contain more than one type of “granular” error finding. The individual error findings shown below are listed in decreasing order of occurrence, grouped according to the major denial categories listed above.

Arkansas Results
A total of two claims were reviewed, with both of the claims either completely or partially denied. This resulted in a claim denial rate of 100 percent. The total dollars reviewed was $10,364.83 of which $10,364.83 was denied, resulting in a charge denial rate of 100 percent. The top denial reasons were identified based on dollars denied.

In order to provide more specific information, regarding the denial reasons identified above, a second level of detail was obtained during Medical Review. Each claim that was reviewed may contain more than one type of “granular” error finding. The individual error findings shown below are listed in decreasing order of occurrence, grouped according to the major denial categories listed above.

Kentucky Results
A total of two claims were reviewed, with both of the claims either completely or partially denied. This results in a claim denial rate of 100 percent. The total dollars reviewed was $13,590.44 of which $13,590.44 was denied, resulting in a charge denial rate of 100.00 percent. The top denial reasons were identified based on dollars denied.

In order to provide more specific information, regarding the denial reasons identified above, a second level of detail was obtained during Medical Review. Each claim that was reviewed may contain more than one type of “granular” error finding. The individual error findings shown below are listed in decreasing order of occurrence, grouped according to the major denial categories listed above.

Louisiana Results
A total of four claims were reviewed, with one of the claims either completely or partially denied. This results in a claim denial rate of 25.0 percent. The total dollars reviewed was $55,986.81of which $13,608.47was denied, resulting in a charge denial rate of 24.31 percent. The top denial reasons were identified based on dollars denied.

In order to provide more specific information, regarding the denial reasons identified above, a second level of detail was obtained during Medical Review. Each claim that was reviewed may contain more than one type of “granular” error finding. The individual error findings shown below are listed in decreasing order of occurrence, grouped according to the major denial categories listed above.

Denial Reasons and Prevention Recommendations

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 six 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

For more information, refer to:

• Code of Federal Regulations, 42 CFR – Section 418.22
• CMS Internet-Only Manuals (IOMs), Publication 100-02, Medicare Benefit Policy Manual, Chapter 9, Section 20
• This article below can be located on the at Jurisdiction M HHH (palmettogba.com) using the search feature: CMS Medicare Learning Network (MLN) Matters article # MM7337 — Hospice Benefit Policy Manual Updates: New Certification Requirements and Revised Conditions of Participation
• Responding to a Hospice Additional Development Request (ADR)

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 website at Jurisdiction M HHH - LCDs, NCDs, Coverage Articles (palmettogba.com).

• 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

For more information, refer to:

• CMS Internet-Only Manuals (IOMs), Publication 100-02, Medicare Benefit Policy Manual, Chapter 9, Section 10
• CMS Internet-Only Manuals (IOMs), Publication 100-04, Medicare Claims Processing Manual, Chapter 11, Section 10

• Palmetto GBA Local Coverage Determinations (LCDs), which are available at Jurisdiction M HHH - LCDs, NCDs, Coverage Articles (palmettogba.com)

• The articles below can be located at Jurisdiction M HHH (palmettogba.com) using the search feature
  • Common Technical Hospice Medical Review Denials and How to Avoid Them
  • CMS Medicare Learning Network (MLN) Matters article # MM7337 — Hospice Benefit Policy Manual Updates: New Certification Requirements and Revised Conditions of Participation
  • Responding to a Hospice Additional Development Request (ADR)

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

For further information on the above Medicare coverage issue, references include, but are not limited to the following:

• CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Chapter 9, Section 40.1.5
• CMS Manual System, Pub 100-04, Medicare Claims Processing Manual, Chapter 11, Section 30.1

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

For more information refer to:

• CMS Internet-Only Manuals (IOMs), Publication 100-02, Medicare Benefit Policy Manual, Chapter 9, Sections 10 and 20.1
• Code of Federal Regulations, 42 CFR – Section 418.22
• The articles below can be located at Jurisdiction M HHH (palmettogba.com) using the search feature
  • Common Technical Hospice Medical Review Denials and How to Avoid Them
  • Responding to a Hospice Additional Development Request (ADR)
  • CMS Medicare Learning Network (MLN) Matters article # MM7337 — Hospice Benefit Policy Manual Updates: New Certification Requirements and Revised Conditions of Participation

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 plan of care must be reviewed, revised, and documented as frequently as the beneficiary's condition requires, but no less frequently than every fifteen (15) calendar days

For further information refer to:

• Change Request 6982

• “Did You Know: Hospice Plans of Care Must Be Submitted When Medical Records are Requested?” This article is available at www.PalmettoGBA.com/HHH using the search feature.
• Code of Federal Regulations, 42 CFR – Section 418.56 and 418.200
• CMS Internet-Only Manual (IOMs), Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.4.1.1

The Next Steps
The service-specific targeted medical review edits for Hospice in Alabama, Arkansas, Kentucky, and Louisiana 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 HH Pre-Claim Review Submission Request form.

Questions regarding this medical review can be directed to the Palmetto GBA Provider Contact Center at 855–696–0705.