New Mexico 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 New Mexico.

  • Total claims reviewed: 5
  • Total dollars reviewed: $12,766.08
  • Total paid: 4
  • Total paid dollars: $12,766.08
  • Total denied: 0 
  • Total denied dollars: $0.00

Information Only — Previous Errors

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

SO – Hospice — Plan of care, SR — Hospice — Initial Hospice Assessment, SU — Hospice — Face-to-Face Evaluation: Missing was 1) IDG/IDT Plan of Care Review/Updates by physician and IDG group at minimum of every 15 days pertinent to hospice billed dates of service 04/01/XX to 04/15/XX. 2) Initial nurse admission assessment for admission date 11/20/XX. 3) Face-to-face encounter requirement being completed prior to benefit period dates 03/19/XX to 05/17/XX.

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

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 & necessary: the submitted documentation does not support a terminal prognosis; the diagnosis of recurrent colon cancer is not substantiated, and the beneficiary is fairly active. Hospice services provided for billed dates are not medically reasonable and necessary for beneficiary admitted on 09/09/XX. The plan was for care planning to be done to determine what the plan would be when this 80-year-old beneficiary could no longer live alone. Beneficiary drives herself to senior center on Mondays through Fridays and took a trip to XXXXX to see balloons. It is noted that hospice was revoked on 11/11/XX before taking a trip to another location. Services included nursing and social worker.

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

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

DMEPOS Competitive Bidding Program

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

MolDX

National Supplier Clearinghouse MAC

PDAC

RRB Specialty MAC Providers

RRB Specialty MAC Beneficiaries

Anonymous

 


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