Postpayment Service-Specific Probe Results for Hospice General Inpatient Care for January through March 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 and Texas, for processing period January through March 2021, are presented here.

Cumulative Results 
A total of 1699 claims were reviewed with 331 of the claims either completely or partially denied, resulting in an overall claim denial rate of 19.48 percent. The total dollars reviewed was $13,520,904.67, of which $2,067,100.74 was denied, resulting in a charge denial rate of 15.29 percent. Overall, there were 12 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
25.98%	5CF91/5CF91	Hospice General Inpatient Reduction — Services Not Reasonable and Necessary	86
23.26%	5FNER/5CNER	The Hospice Election Does Not Meet Statutory/Regulatory Requirements	77
13.60%	5FFH9/5CFH9	Physician Narrative Statement Not Present or Not Valid	45
6.34%	5FFH6/5CFH6	Initial Certification Not Timely	21
4.83%	5FFTF/5CFTF	Face-to-Face Encounter Requirements Not Met	16

Alabama Results
A total of 134 claims were reviewed in Alabama, with 26 of the claims either completely or partially denied. This resulted in a claim denial rate of 19.40 percent. The total dollars reviewed was $1,061,426.03, of which $125,933.81 was denied, resulting in a charge denial rate of 11.86 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
38.46%	5CF91/5CF91	Hospice General Inpatient Reduction — Services Not Reasonable and Necessary	10
19.23%	5FFH9/5CFH9	Physician Narrative Statement Not Present or Not Valid	5
7.69%	5CF9U	Hospice GIP Reduction — Services Not Due to Terminal Illness	2
7.69%	5FFH6/5CFH6	Initial Certification Not Timely	2
7.69%	5FFIP/5CFIP	Invalid Plan of Care	2

Arkansas Results
A total of 33 claims were reviewed in Arkansas, with six of the claims either completely or partially denied. This resulted in a claim denial rate of 18.18 percent. The total dollars reviewed was $261,826.56, of which $31,694.39 was denied, resulting in a charge denial rate of 12.11 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
50.00%	5FFNP/5CFNP	No Plan of Care Submitted	3
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
16.67%	5FFH9/5CFH9	Physician Narrative Statement Not Present or Not Valid	1
16.67%	5FF36/5CF36	Documentation Submitted Does Not Support Prognosis of Six Months or Less	1

Florida Results
A total of 321 claims were reviewed in Florida, with 58 of the claims either completely or partially denied. This resulted in a claim denial rate of 18.07 percent. The total dollars reviewed was $2,850,467.83, of which $349,068.34 was denied, resulting in a charge denial rate of 12.25 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
50.00%	5CF91/5CF91	Hospice General Inpatient Reduction — Services Not Reasonable and Necessary	29
13.79%	5FFH9/5CFH9	Physician Narrative Statement Not Present or Not Valid	8
10.34%	5FNER/5CNER	The Hospice Election Does Not Meet Statutory/Regulatory Requirements	6
6.90%	5CF92/5CF92	Hospice Continuous Care Hours Reduction	4
5.17%	5FFTF/5CFTF	Face-to-Face Encounter Requirements Not Met	3

Georgia Results
A total of 220 claims were reviewed in Georgia, with 42 of the claims either completely or partially denied. This resulted in a claim denial rate of 19.09 percent. The total dollars reviewed was $1,630,906.30, of which $239,676.72 was denied, resulting in a charge denial rate of 14.70 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%	5CF91/5CF91	Hospice General Inpatient Reduction — Services Not Reasonable and Necessary	12
16.67%	5FNER/5CNER	The Hospice Election Does Not Meet Statutory/Regulatory Requirements	7
14.29%	5FFH9/5CFH9	Physician Narrative Statement Not Present or Not Valid	6
11.90%	5FFH6/5CFH6	Initial Certification Not Timely	5
7.14%	5FFTF/5CFTF	Face-to-Face Encounter Requirements Not Met	3

Illinois Results
A total of 57 claims were reviewed in Illinois, with 13 of the claims either completely or partially denied. This resulted in a claim denial rate of 22.81 percent. The total dollars reviewed was $431,060.34, of which $92,665.14 was denied, resulting in a charge denial rate of 21.50 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
38.46%	5FNER/5CNER	The Hospice Election Does Not Meet Statutory/Regulatory Requirements	5
15.38%	5CF91/5CF91	Hospice General Inpatient Reduction — Services Not Reasonable and Necessary	2
15.38%	5FFH6/5CFH6	Initial Certification Not Timely	2
7.69%	5FFH3/5CFH3	No Certification for Dates Billed	1
7.69%	5FFH9/5CFH9	Physician Narrative Statement Not Present or Not Valid	1

Indiana Results
A total of 51 claims were reviewed in Indiana, with nine of the claims either completely or partially denied. This resulted in a claim denial rate of 17.65 percent. The total dollars reviewed was $388,307.57, of which $58,410.92 was denied, resulting in a charge denial rate of 15.04 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
44.44%	5FFH9/5CFH9	Physician Narrative Statement Not Present or Not Valid	4
22.22%	5CF9U	Hospice GIP Reduction — Services Not Due to Terminal Illness	2
11.11%	5FNER/5CNER	The Hospice Election Does Not Meet Statutory/Regulatory Requirements	1
11.11%	5FFH3/5CFH3	No Certification for Dates Billed	1
11.11%	5FNOE/5CNOE	Partial Denial of Services Due to no Valid Election Statement Submitted	1

Kentucky Results 
A total of 84 claims were reviewed in Kentucky, with 21 of the claims either completely or partially denied. This results in a claim denial rate of 25 percent. The total dollars reviewed was $676,831.91, of which $156,952.33 was denied, resulting in a charge denial rate of 23.19 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
90.48%	5FNER/5CNER	The Hospice Election Does Not Meet Statutory/Regulatory Requirements	19
4.76%	5CF91/5CF91	Hospice General Inpatient Reduction — Services Not Reasonable and Necessary	1
4.76%	5FFH6/5CFH6	Initial Certification Not Timely	1

Louisiana Results 
A total of 175 claims were reviewed in Louisiana, with 38 of the claims either completely or partially denied. This results in a claim denial rate of 21.71 percent. The total dollars reviewed was $1,348,300.03, of which $276,649.89 was denied, resulting in a charge denial rate of 20.52 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
21.05%	5CF91/5CF91	Hospice General Inpatient Reduction — Services Not Reasonable and Necessary	8
15.79%	5FFH9/5CFH9	Physician Narrative Statement Not Present or Not Valid	6
15.79%	5FNER/5CNER	The Hospice Election Does Not Meet Statutory/Regulatory Requirements	6
10.53%	5FFH3/5CFH3	No Certification for Dates Billed	4
7.89%	5FFNP/5CFNP	No Plan of Care Submitted	3

Mississippi Results
A total of 27 claims were reviewed in Mississippi, with four of the claims either completely or partially denied. This resulted in a claim denial rate of 14.81 percent. The total dollars reviewed was $191,135.66, of which $18,766.99 was denied, resulting in a charge denial rate of 9.82 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
50.00%	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
50.00%	5FFH9/5CFH9	Physician Narrative Statement Not Present or Not Valid	2

New Mexico Results
A total of 15 claims were reviewed in New Mexico, with one of the claims either completely or partially denied. This resulted in a claim denial rate of 6.67 percent. The total dollars reviewed was $122,967.37, of which $9,348.17 was denied, resulting in a charge denial rate of 7.60 percent. The top denial reason was identified, and the number of occurrences based on dollars denied are:

Percent of Total Denials	Denial Code	Denial Description	Number of Occurrences
100%	5FFTF/5CFTF	Face-to-Face Encounter Requirements Not Met	1

North Carolina Results
A total of 249 claims were reviewed in North Carolina, with 42 of the claims either completely or partially denied. This resulted in a claim denial rate of 16.87 percent. The total dollars reviewed was $1,943,693.37, of which $254,284.32 was denied, resulting in a charge denial rate of 13.08 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
23.81%	5CF91/5CF91	Hospice General Inpatient Reduction — Services Not Reasonable and Necessary	10
19.05%	5FNER/5CNER	The Hospice Election Does Not Meet Statutory/Regulatory Requirements	8
14.29%	5FFH6/5CFH6	Initial Certification Not Timely	6
11.90%	5CF9U	Hospice GIP Reduction — Services Not Due To Terminal Illness	5
9.52%	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	4

Ohio Results
A total of 53 claims were reviewed in Ohio, with 12 of the claims either completely or partially denied. This resulted in a claim denial rate of 22.64 percent. The total dollars reviewed was $416,783.98, of which $76,784.23 was denied, resulting in a charge denial rate of 18.42 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
41.67%	5FNER/5CNER	The Hospice Election Does Not Meet Statutory/Regulatory Requirements	5
16.67%	5FFH9/5CFH9	Physician Narrative Statement Not Present or Not Valid	2
16.67%	5FFIP/5CFIP	Invalid Plan of Care Submitted	2
8.33%	5CF91/5CF91	Hospice General Inpatient Reduction — Services Not Reasonable and Necessary	1
8.33%	5FFNP/5CFNP	No Plan of Care Submitted	1

Oklahoma Results
A total of 11 claims were reviewed in Oklahoma, with one of the claims either completely or partially denied. This resulted in a claim denial rate of 9.09 percent. The total dollars reviewed was $83,334.05, of which $3,469.97 was denied, resulting in a charge denial rate of 4.16 percent. The top denial reason was identified, and the number of occurrences based on dollars denied are:

Percent of Total Denials	Denial Code	Denial Description	umber of Occurrences
100%	5CF91/5CF91	Hospice General Inpatient Reduction — Services Not Reasonable and Necessary	1

South Carolina Results
A total of 198 claims were reviewed in South Carolina, with 39 of the claims either completely or partially denied. This resulted in a claim denial rate of 19.70 percent. The total dollars reviewed was $1,527,145.63, of which $241,027.28 was denied, resulting in a charge denial rate of 15.78 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
35.90%	5FNER/5CNER	The Hospice Election Does Not Meet Statutory/Regulatory Requirements	14
20.51%	5CF91/5CF91	Hospice General Inpatient Reduction — Services Not Reasonable and Necessary	8
15.38%	5FFH9/5CFH9	Physician Narrative Statement Not Present or Not Valid	6
7.69%	5FFH6/5CFH6	Initial Certification Not Timely	3
5.13%	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

Tennessee Results
No claims were reviewed in Tennessee during this period.

Texas Results
A total of 71 claims were reviewed in Texas, with 19 of the claims either completely or partially denied. This resulted in a claim denial rate of 26.76 percent. The total dollars reviewed was $586,718.04, of which $132,368.24 was denied, resulting in a charge denial rate of 22.56 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%	5FNER/5CNER	The Hospice Election Does Not Meet Statutory/Regulatory Requirements	5
21.05%	5CF91/5CF91	Hospice General Inpatient Reduction — Services Not Reasonable and Necessary	4
21.05%	5FNOE/5CNOE	No Valid Election Statement Submitted	4
10.53%	5FFNP/5CFNP	No Plan of Care Submitted	2
10.53%	5FFTF/5CFTF	Face to Face Encounter Requirements Not Met	2

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

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

• CMS Internet-Only Manuals (IOMs), 100-02, Medicare Benefit Policy Manual, Chapter 9, Section 40.1.5 (PDF, 453.26 KB)
• CMS Internet-Only Manuals (IOMs), 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, 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 signature of the individual or representative

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

• CMS Internet-Only Manuals (IOMs), 100-02, Medicare Benefit Policy Manual, Chapter 9, Section 40.1.5 (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 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 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

More Information

• Code of Federal Regulations, 42 CFR — Section 418.22
• CMS Internet-Only Manuals (IOMs), 100-02, Medicare Benefit Policy Manual, Chapter 9, Section 40.1.5 (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 Manuals (IOMs), 100-02, Medicare Benefit Policy Manual, Chapter 9, Section 40.1.5 (PDF, 453.26 KB)
• Code of Federal Regulations, 42 CFR — Section 418.22
   

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 Manuals (IOMs), 100-02, Medicare Benefit Policy Manual, Chapter 9, Section 40.1.5 (PDF, 453.26 KB)
   

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. 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 plan of care. 

More Information

• Code of Federal Regulations, 42 CFR — Section 418.56 and 418.200
• CMS Internet-Only Manuals (IOMs), 100-02, Medicare Benefit Policy Manual, Chapter 9, Section 40.1.5 (PDF, 453.26 KB)
• CMS Internet-Only Manual (IOMs), 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.4.1.1 (PDF, 652.5 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 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 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 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 plan of care.

More Information

• Code of Federal Regulations, 42 CFR — Section 418.56 and 418.20
• CMS Internet-Only Manual (IOMs), 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
   

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 LCDs, NCDs, and Coverage 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 co-morbidity, which may further support the terminal condition of the beneficiary and the continuing appropriateness of hospice care

More Information

• CMS Internet-Only Manuals (IOMs), 100-02, Medicare Benefit Policy Manual, Chapter 9, Section 10 and Section 40 (PDF, 453.26 KB)
• CMS Internet-Only Manuals (IOMs), 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
   

5CF92/5CF92 — Hospice Continuous Care Hours Reduction

Reason for Denial 
Hospice continuous care hours have been reduced to the routine care rate.

How to Avoid This Denial
Submit documentation to provider clear evidence the continuous care is being provided during a period of crisis.

• A period of crisis is defined as a time in which the beneficiary requires predominately nursing care to achieve palliation or management of acute medical symptoms
• For continuous care to be covered, care must be provided for a minimum of 8 hours during a 24-hour day which begins and ends at midnight
• The documentation submitted for review should reflect the care provided was predominately nursing care by either a registered nurse (RN) or licensed practical nurse (LPN), which means at least half of the hours of care were provided by an RN or LPN
• Ensure documentation submitted for review includes the number of hours of care provided by each discipline and it should match the number of units of continuous care hours billed

More Information

• CMS Internet-Only Manuals (IOMs), 100-02, Medicare Benefit Policy Manual, Chapter 9, Section 40.2.1 (PDF, 453.26 KB)
• CMS Internet-Only Manuals (IOMs), 100-04, Medicare Claims Processing Manual, Chapter 11, Section 30.1 (PDF, 521.46 KB)
• CMS Internet-Only Manuals (IOMs), 100-02, Medicare Benefit Policy Manual, Chapter 9, Sections 10, 20.2 and 20.2.1 (PDF, 453.26 KB)
• Code of Federal Regulations, 42 CFR — Sections 418.20
   

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 Manuals (IOMs), 100-02, Medicare Benefit Policy Manual, Chapter 9, Section 10 and Section 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. 

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

• CMS Internet-Only Manuals (IOMs), 100-02, Medicare Benefit Policy Manual, Chapter 9, Section 40.1.5 (PDF, 453.26 KB)
• CMS Internet-Only Manuals (IOMs), 100-04, Medicare Claims Processing Manual, Chapter 11, Section 30.1 (PDF, 521.46 KB)
   

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 HMB 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 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 Manuals (IOMs), 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
   

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 and Texas 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.