Florida 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 Florida.

  • Total claims reviewed: 84
  • Total dollars: $336,239.83
  • Claims paid: 67
  • Dollars paid: $288,320.98
  • Claims denied: 17
  • Dollars denied: $47,918.85
  • Claims with error code Insufficient documentation (21): 6
  • Claims with error code Not medically necessary (25): 6
  • Claims with error code Incorrect coding (31): 4
  • Claims with error code Unbundling (60): 1

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

  1. SQ — MD Certification/Recertification Is Missing or Inadequate: The physician’s certification of terminal illness that includes a brief narrative was missing.
  2. SU — Face-to-Face Evaluation Is Missing or Inadequate: The face-to-face encounter note, including attestation that occurred prior to beginning of benefit period 9 was missing.
  3. SO — Plan of Care Is Missing or Inadequate: Initial comprehensive nursing assessment and authenticated IDT POC review/update prior to 07/08/XX that documents discussion with physician and includes signatures of attendees is missing.
  4. SP — Beneficiary Election Form: Form is missing or inadequate.
  5. ST – Service Documentation on Billed DOS: Documentation of services provided on the billed date (s) of service is missing or inadequate.

To avoid errors for Insufficient Documentation:
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:

  • The submitted documentation does not support a terminal prognosis. The beneficiary is table with chronic conditions; no evidence of decline or progression of condition.
  • Documentation does not support a terminal prognosis: the beneficiary has class II heart disease with a 50% EF; few symptoms; no weight loss; there is no documentation of decline or progression of his condition
  • Documentation does not support a terminal prognosis. The beneficiary is stable and weight has increased.
  • Documentation does not support a terminal prognosis. The beneficiary is alert & oriented, ambulates, eats well; no evidence of decline or progression of condition.
  • Documentation does not support a terminal prognosis

Here are some tips to prevent this error:

Documentation to support terminal prognosis (examples 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 IDT/POC meeting which covers time period 08/31/16 to 09/13/16 was not done until 09/09/16. Review supports recoding of billed units of service from 31 to 30.
  • Documentation supports a change in the UOS for the hospice services routine home care from (31) to (27) based on the missing IDG POC review/update, applicable to dates of service 08/01/2016, 08/02/2016, 08/03/2016, and 08/04/2016
  • Documentation supports a change in UOS from (31) to (16) for hospice routine home care services provided in a LTC, based on the missing 1) Content to the IDG POC update for 12/02/2016, that includes disciplines involved; and 2) IDG POC review/update prior to 12/02/2016 that supports date of service 12/01/2016
  • Documentation submitted supports a change in UOS from (31) to (27). Missing IDT/updated plan of care note for 12/29/16 to support the Hospice services for 1/1/17-1/4/17. 

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

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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