Illinois 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 Illinois.

  • Total claims reviewed: 35
  • Total dollars reviewed: $96,369.71
  • Claims paid: 30 
  • Dollars paid: $81,772.57
  • Claims denied: 5
  • Dollars denied : $14,597.14
  • Claims with error code Insufficient Documentation (21): 3
  • Claims with error code Not Medically Necessary (25): 1
  • Claims with error code Incorrectly Coded (31): 1

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

  • 00195 — Hospice — Physician Narrative as Part of the Certification/Recertification Supporting Terminal Illness: Missing was Hospice Medical Director's certification with valid narrative statement and attestation statement to support services for 7/26/XX-7/31/XX.
  • SQ — Hospice — MD Certification/Recertification Is Missing or Inadequate: Verbal certification for Hospice medical director for 7/26/XX-10/23/XX and verbal certification for attending physician for benefit period 7/26/XX-10/23/XX.
  • SL — A/D/DME/DRG — A Signature Log: A signature log for Dr. King is missing.
  • SO — Hospice — Plan of Care Is Missing or Inadequate: IDT POC notes for 05/18/XX and 05/25/XX, that includes updated comprehensive assessment and progress towards goals specified in the plan of care.
  • 48 — A/D/DME/DRG — Illegible Signature on Medicare Required Document: The submitted documentation has an illegible signature in the attending section.

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 ll 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, 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:

  • Documentation does not support a terminal prognosis. The beneficiary appears stable with chronic conditions; no evidence of decline or progression of her 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

  • The submitted documentation supports a changed in UOS for the billed routine home care hospice services provided in SNF for dates of service 02/01/XX to 02/28/XX. Certification of terminal illness was not signed prior to claim entry date. Therefore, change UOS of service from 28 to 3.

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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Palmetto GBA Home

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Jurisdiction J Part A MAC

Jurisdiction J Part B MAC

Jurisdiction M Part A MAC

Jurisdiction M Part B MAC

Jurisdiction M Home Health and Hospice MAC


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RRB Specialty MAC Beneficiaries



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