Pre-Payment Review Results for Hospice GIP Care for July to September 2024

Published 12/27/2024

Pre-Payment Review Results for Hospice General Inpatient (GIP) Care for Targeted Probe and Educate (TPE) for July to September 2024

The Centers for Medicare & Medicaid Services (CMS) implemented the TPE process for Hospice GIP care. The reviews with edit effectiveness are presented here for states in Jurisdiction M.

Cumulative Results

Table 1. Cumulative Results.
Number of Providers with Edit Effectiveness Providers Compliant Completed/Removed After Probe Providers Non-Compliant/Removed for Other Reason Providers Non-Compliant/Removed for Other Reason
16 12 4 0
Table 2. Cumulative Results.
Number of Claims with Edit Effectiveness Number of Claims Denied Overall Claim Denial Rate Total Dollars Reviewed Total Dollars Denied Overall Charge Denial Rate
366 81 22% $3,686.949.34 $711,204.10 19%

Probe One Findings

Table 3. Probe One Findings.
State Number of Providers with Edit Effectiveness Providers Compliant Completed/Removed After Probe Providers Non-Compliant Progressing to Subsequent Probe Providers Non-Compliant/Removed for Other Reason
Ga. 2 1 1 0
Ill. 1 1 0 0
Ind. 2 1 1 0
N.C. 1 1 0 0
Ohio 2 2 0 0
Texas 7 5 2 0
Table 4. Probe One Findings.

State

 Number of Claims with Edit Effectiveness Number of Claims Denied Overall Claim Denial Rate Total Dollars Reviewed Total Dollars Denied Overall Charge Denial Rate
Ga. 59 20 34% $640,014.57 $178,556.62 28%
Ill. 27 5 19% $362,408.98 $29,552.57 8%
Ind. 50 24 48% $515,850.24 $227,277.73 44%
N.C. 30 4 13% $345,565.36 $41,433.49 12%
Ohio 37 4 11% $338,044.73 $32,946.31 10%
Texas 143 23 16% $1,288,920.51 $194,472.61 15%

Probe Two Findings

Table 5. Probe Two Findings.
State Number of Providers with Edit Effectiveness Providers Compliant Completed/Removed After Probe Providers Non-Compliant Progressing to Subsequent Probe Providers Non-Compliant/Removed for Other Reason
Texas 1 1 0 0
Table 6. Probe Two Findings.
State Number of Claims with Edit Effectiveness Number of Claims Denied Overall Claim Denial Rate Total Dollars Reviewed Total Dollars Denied Overall Charge Denial Rate
Texas 20 1 5% $196,144.95 $6,970.77 4%

Risk Category
The risk categories for hospice GIP care are defined as:

Table 7. Risk Category.
Risk Category Error Rate
Minor 0–20%
Major 21–100%

Figure 1. Risk Category for Hospice GIP.

Pie chart showing 25% major findings and 75% minor findings

Top Denial Reasons and Recommendations

Table 8. Top Denial Reasons.
Percent of Total Denials Denial Code Denial Description Number of Occurrences
26% 5CF91 Hospice General Inpatient Reduction — Services Not Reasonable and Necessary 7
22% 56900 Requested Records Not Submitted Timely 6
19% 5FFH6, 5CFH6 Initial Certification Not Timely 5
18% 5FNER, 5CNER The Hospice Election Statement Does Not Meet Statutory/Regulatory Requirements 5
15% 5FFTF, 5CFTF Face-to-Face Encounter Requirements Not Met 4

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

References

56900 — Requested Records Not Submitted Timely

Reason for Denial
The services billed were not covered because the documentation was not received in response to the Additional Documentation Request (ADR) and therefore, we were unable to determine the medical necessity of the service billed. The provider has 45 days from the date the ADR was generated to respond with medical records. If less than 120 days after denial notification on the remittance advice, submit records to the contractor requesting records at the address listed on the original ADR to request reopening. Do not resubmit the claim.

How to Avoid This Denial

  • Be aware of the ADR date and the need to submit medical records within 45 days of the ADR date
  • Submit the medical records as soon as the ADR is received
  • Monitor the status of your claims in Direct Data Entry (DDE) and begin gathering the medical records as soon as the claim goes to the location of SB6001
  • Return the medical records to the address on the ADR. Be sure to include the appropriate mail code or station number. This ensures that your responses are promptly routed to the medical review department. Fax and electronic data submissions are also accepted as indicated on the ADR.
  • Gather all of the information needed for the claim and submit it all at one time
  • Attach a copy of the ADR request to each individual claim
  • If responding to multiple ADRs, separate each response and attach a copy of the ADR to each individual set of medical records. Make sure each set of medical records is individually identifiable and bound securely to ensure that no documentation is detached or lost. Do not use paper clips.
  • Do not mail packages C.O.D.; we cannot accept them

References

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

References

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 particular 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, 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

For hospice elections beginning on or after October 1, 2020, the hospice must provide:

  1. Information on individual cost-sharing for hospice services;
  2. Notification of the individual’s (or representative’s) right to receive an election statement addendum if there are conditions, items, services, and drugs the hospice has determined to be unrelated to the individual’s terminal illness and related conditions and would not be covered by the hospice;
  3. Information on the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO), including the right to immediate advocacy and BFCC-QIO contact information; and \
  4. The signature of the individual or representative

References

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 6 months or less, should the illness run its normal course

References

Education
Palmetto GBA offers providers selected for TPE an individualized education session to discuss each claim denial. This is an opportunity to learn how to identify and correct claim errors. A variety of education methods are offered such as webinar sessions, web-based presentations or teleconferences. Other education methods may also be available. Providers do not have to be selected for TPE to request education. If education is desired, please complete the Education Request Form.

Next Steps
Providers found to be non-compliant (major risk category/denial rate of 21–100 percent) at the completion of TPE Probe 1 will advance to Probe 2, and providers found to be non-compliant (major risk category/denial rate of 21–100 percent) at the completion of TPE Probe 2 will advance to Probe 3 of TPE after at least 45 days from completing the 1:1 post-probe education call date.


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