Texas 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 Texas.

  • Total claims reviewed: 84
  • Total dollars: $251,464.56
  • Claims paid: 9
  • Dollars paid: $209,760.77
  • Claims denied: 19
  • Dollars denied: $41,703.79
  • Claims with error code Insufficient documentation (21): 11
  • Claims with error code Not medically necessary (25): 1
  • Claims with error code Incorrectly coded (31): 6
  • Claims with error code Other errors (90): 1

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

  • SO — Hospice — Plan of Care: Missing signed POC for benefit period #1 12/12/XX- 3/11/XX; documentation for the last IDT POC conference in December is needed to support coverage requirements for 01/01/XX – 01/03/XX; and 01/01/XX-01/31/XX nurse, social worker and aide notes.
  • SP — Hospice-Beneficiary Election Form: Missing EOB and signed recertification for benefit period of 07/21/XX to 09/18/XX.
  • SQ — Hospice — MD Certification/Recertification: Physician certification narrative that includes specific clinical findings supporting a life expectancy of 6 months or less.
  • SQ — Hospice — MD Certification/Recertification: Missing was hospice certification of terminal illness for benefit period dates 01/26/XX to 04/24/XX which meets Medicare requirements.
  • SR — Hospice — Initial Assessment Is Missing or Inadequate: 06/30/XX initial comprehensive clinical information assessment is missing.
  • ST — Hospice — Document of Services Provided: Signed RN home visit notes that document times for RN visits on 08/23/XX and 08/26/XX or attestations to the applicable entries on the submitted “solutions Report/Timesheets.”
  • SU — Hospice — Face-to-Face Evaluation: Missing was face-to-face attestation and encounter document for date 06/29/XX which supports the subsequent episode #12 dates 07/10/XX to 09/07/XX.
  • 00195 — Hospice Physician Narrative: Physician certification narrative that includes specific clinical findings supporting a life expectancy of 6 months or less; the submitted narrative is insufficiently detailed.

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 — Medically Unnecessary Service or Treatment

Error Details:

  • Hospice services not reasonable and necessary: documentation does not support a terminal prognosis: beneficiary is stable with chronic issues; 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:

  • Missing is documentation which supports IDT/POC meeting was held for date 07/26/XX. Review supports recoding of billed units of service from 31 to 25
  • Billed for hospice care from 11/01/XX to 11/30/XX. Missing IDT note to support POC for 11/01/XX to 11/08/XX. Down code units from 30 to 22.
  • Documentation submitted supports a change in UOS for Continuous Home Care Hospice Services from (60) to (49) based on the physician’s order for change in level of care to begin, and nursing notes for continuous care for date of service 11/09/XX.
  • Documentation submitted supports a change in UOS for Hospice services from (28) to (16)
  • Documentation supports a change in UOS from (30) to (23). Last IDT meeting in March was 03/23/XX. Next meeting would have been due no later than 15 days later on 04/06/XX. The meetings submitted for April were on 04/13/XX and 04/27/XX. There is no plan of care update to support the billed Hospice services for dates 04/06/XX – 04/12/XX.
  • Documentation supports a change in UOS for hospice routine home care services from (31) to (4) based on the missing valid face-to-face attestation for benefit period 9 (03/29/XX - 05/27/XX)

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

CERT Reviewer Error: 90 — Other Errors
Error Details:

  • Provider billed Routine Home Hospice Care (HCPC Q5001) on Dates of Service 08/02/XX – 08/04/XX resulting in payment for direct skilled nursing services on dates 08/02/20XX, 08/03/XX, and 08/04/XX which were provided within the last 7 days of life. To qualify for the SIA (Service Intensity Add-on) payment, the services must be provided during routine home care. Submitted documentation supports Hospice services were provided in an inpatient hospital rather than in the beneficiary's home/residence; therefore no additional payment is made for the billed skilled nursing visits.

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

Other Palmetto GBA Sites

Palmetto GBA Home

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Jurisdiction J Part A MAC

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Jurisdiction M Part A MAC

Jurisdiction M Part B MAC

Jurisdiction M Home Health and Hospice MAC

MolDX

National Supplier Clearinghouse MAC

PDAC

RRB Specialty MAC Providers

RRB Specialty MAC Beneficiaries

Anonymous

 


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