Ohio Hospice CERT Data

The Comprehensive Error Rate Testing (CERT) program looks for improper payments on Medicare claims. Based on the 2018 annual report, here is the hospice CERT information for Ohio.

  • Total claims reviewed: 60
  • Total dollars reviewed: $195.837.49
  • Claims paid: 46 
  • Dollars paid: $157,342.38
  • Claims denied: 11
  • Dollars denied : $38,495.11
  • Claims with error code Insufficient Documentation (21): 8
  • Claims with error code Not Medically Necessary (25): 3
  • Claims with error code Incorrectly Coded (31): 3

CERT Reviewer Error: 21 — Insufficient Documentation
Error Subcategory Details:

  • 00195 — Hospice — Physician Narrative as Part of the Certification/Recertification Supporting Terminal Illness: Documentation that supports performance of bi-weekly IDT POC updates with physician’s involvement for billed DOS 09/01/XX – 09/30/XX.
  • SO — Hospice — Pan of Care Is Missing or Inadequate: IDT meeting notes/POC updates (for last meeting in June, 07/13/XX, 07/27/XX) to support Hospice services for 07/01/XX-07/31/XX.
  • SQ — Hospice — MD Certification/Recertification: Missing valid Medical Director's certification of terminal illness that meets the documentation requirements; and valid narrative that was composed by the Medical Director and includes the required attestation statement.
  • SU — Hospice — Face-to-Face Evaluation Is Missing or Inadequate: Missing Face-to-Face encounter for Benefit Period #9 (08/15/XX - 10/13/XX recertification.
  • ST — Hospice — Service documentation on billed DOS: Missing is Initial nurse visit note for date 09/07/XX with documented visit time which supports 6 UOS.

Here are some tips to prevent this error:

1. Make sure the following information is submitted in the record for review:

  • Hospice election 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
  • The signature of the individual or representative
  • The plan of care (POC), which is reviewed, revised and documented as frequently as the beneficiary's condition requires, but no less frequently than every fifteen (15) calendar days
  • 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 a separate and distinct section of, or an addendum to, the recertification form, and must be clearly titled
    • When a nurse practitioner 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

2. Comprehensive assessment:

  • Physician Certification
  • Signed and dated
  • Reference to the benefit period
  • Verbal certification included, if applicable
  • Documentation that medical director is the attending, if applicable
  • Narrative/face-to-face encounter narrative
  • Documentation of clinical findings
  • Attestation

CERT Reviewer Error: 25 — Not Medically Necessary
Error Details:

Hospice Services Not Reasonable and Necessary:

  • GIP level of care not reasonable and necessary: submitted documentation does not support care that could not be provided in another setting; the beneficiary is nauseous with occasional emesis; taking clear liquids, and oral meds.
  • Documentation does not support a terminal prognosis: the beneficiary is stable; there is no evidence of decline or progression of condition

Here are some tips to prevent this error:

Documentation to support terminal prognosis (example may include)

  • History
  • Progression of illness/disease
  • Recent changes
  • Exacerbation of symptoms
  • Comorbidities
  • Secondary conditions
  • Variables that are measureable
  • Labs
  • PPS/Karnofsky scale
  • FAST scale for Alzheimer’s patients
  • Weight loss
  • BMI
  • Percentage of meals eaten
  • Vital signs
  • IDG meeting notes

CERT Reviewer Error: 31 — Service Incorrectly Coded
Error Details:

  • IDT POC review/update, prior to 11/02/XX, that documents discussion with physician in attendance, and includes signatures of attendees, to support billed date of service 11/01/XX; therefore UOS changed from (23) to (22)
  • Documentation supports the change in UOS from (31) to (24). Missing the IDT note/updated POC due on 03/02/XX to support Hospice services for 03/02/XX-03/08/XX
  • Documentation supports a change in the units of service for billed hospice claim dates of service 03/01/XX to 03/31/XX. Missing is documentation which supports IDG/POC update meetings with physician involvement were done in March. Review finds that the initial POC for date 02/22/XX was present which covers the first 14 days of service. Supports change in UOS from 31 to 7.

Here are some tips to prevent this error:

  • Make sure the date(s) of service are documented
  • Ensure the proper principle diagnosis and principle procedure is coded correctly
  • Include all documentation to support the codes billed
  • Use a checklist to ensure all of the essential pieces are included in the record
  • Make sure that both sides of double sided documents are submitted
  • Remember it is the billing provider’s responsibility to obtain and necessary information required for the record review, regardless of the location of the documentation

Contact Palmetto GBA JM Part HHH Medicare

Email HHH

Contact a specific JM HHH department

Provider Contact Center: 855-696-0705

TDD: 866-830-3188

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