Tennessee 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 Tennessee.

  • Total claims reviewed: 17
  • Total dollars: $55,927.39
  • Claims paid: 9
  • Dollars paid: $38,208.76
  • Claims denied: 8
  • Dollars denied: $17,718.63
  • Claims with error code Insufficient Documentation (21): 4
  • Claims with error code Incorrectly Coded (31): 4

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

  • SO — Hospice — Plan of Care: Missing plan of care (POC) applicable to 06/01/XX – 06/28/XX.
  • SQ — Hospice — MD Certification/Recertification: Missing recertification of terminal illness for benefit period #2 and hospice physician’s recertification narrative for BP #3 that is sufficiently detailed to support prognosis and includes an attestation statement that the physician “composed” the narrative.
  • SR — Hospice — Initial Hospice Assessment is Missing or Inadequate: Missing initial comprehensive assessment applicable to 04/10/XX admission date.
  • ST — Hospice — Documentation of Service Provided: Missing documentation that supports participation of IDT team members and approval of hospice physician for IDT POC review and RN note which supports billed SIA visit.
  • 00195 — Hospice — Physician Narrative as Part of the Certification/Recertification supporting terminal illness: Valid physician’s narrative statement as part of the hospice certification for billed dates.

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 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 is applicable
  • Narrative/face-to-face encounter narrative
  • Documentation of clinical findings
  • Attestation

CERT Reviewer Error: 31 — Incorrectly Coded
Error Details:

  • Documentation supports a change in UOS from 19 to 14
  • Documentation submitted supports a change in UOS for the routine level of home care from (31) to (5) based on the missing IDT POC update, prior to 10/04/XX, and the missing F2F attestation for benefit period 9 (10/09/XX - 02/07/XX)
  • Documentation submitted supports a change in UOS for hospice services from 31 to 28
  • Documentation submitted supports a change in UOS for routine hospice care from Q5001 (15) UOS to Q5001 (13) UOS based on the missing IDT POC update report for 02/17/XX, applicable to billed dates of service 03/01/XX and 03/02/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

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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