Pre-Payment Review Results for Texas Hospice Provisional Period of Enhanced Oversight for October to December 2024

Published 03/10/2025

Pre-Payment Review Results for Hospice Provisional Period of Enhanced Oversight (PPEO) on New Hospices in Texas for October to December 2024

The Centers for Medicare & Medicaid Services (CMS) implemented the Probe and Educate process for PPEO on New Hospices in Texas. The reviews with edit effectiveness are presented here for Jurisdiction M.

Cumulative Results

Table 1. Cumulative Results.
Number of Providers with Edit Effectiveness Providers Compliant Completed/Removed Providers Non-Compliant Progressing to Subsequent Probe
21 11 10
Table 2. Cumulative Results.
Total Number of Claims with Edit Effectiveness Total Number of Claims Denied Overall Claim Denial Rate Total Dollars Reviewed Total Dollars Denied Overall Charge Denial Rate
161 37 23% $533,950.51 $139,608.26 26%

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
Texas 5 3 2
Table 4. Probe One Findings.
State Total Number of Claims with Edit Effectiveness Total Number of Claims Denied Overall Claim Denial Rate Total Dollars Reviewed Total Dollars Denied Overall Charge Denial Rate
Texas 31 3 10% $82,091.83 $13,099.83 16%

Probe Two Findings

Table 5. Probe Two Findings.
State Number of Providers with Edit Effectiveness Providers Compliant Completed/Removed Providers Non-Compliant Progressing to Subsequent Probe
Texas 16 8 8
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 130 34 26% $451,858.68 $136,508.43 30%

Risk Category

The categories for Hospice PPEO on New Hospices in Texas are defined as:

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

Figure 1. Risk Category for Hospice PPEO.

Pie chart showing 48% major and 52% minor findings

Top Denial Reasons

Table 8. Top Denial Reasons.
Percent of Total Denials Denial Code Denial Description Number of Occurrences
52% 5FF36, 5CF36 Documentation Submitted Does Not Support Prognosis of Six Months or Less 14
15%

5FFTF, 5CFTF

 Face to Face Encounter Requirements Not Met 4
11% 5FFH9, 5CFH9 Physician Narrative Statement Not Present or Not Valid  3
7% 5FFNP, 5CFNP No Plan of Care  2

4%

5FFH3, 5CFH3

No Certification for Dates Billed

1

Denial Reasons and Recommendations

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 prognoses 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
  • 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

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 a 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

References

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 directly above the physician signature attesting that by signing, the physician confirms that he or 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

References

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 (POC) for all or some of the dates billed. Claims with dates of service beginning July 19, 2010, require that a valid 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 POC for dates of service billed when responding to ADR request 
  • All dates billed must be covered by a POC 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 POCs 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 POC 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 POC
  • 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 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 POC.

References

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

References

Education
Palmetto GBA offers providers selected for review 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 review to request education. If education is desired, please complete the Education Request Form (PDF). 

Next Steps
Providers found to be non-compliant (major risk category/denial rate of 21–100 percent) at the completion of PPEO 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 PPEO Probe 2 may potentially advance to a subsequent Probe for TPE after at least 35 days from issuance of results letter.


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