Service Specific Post Payment Review - Hospice GIP Services Over 7 Days (5ANLP) for JK A Regions: NY/CT, MA, ME, NH/VT and RI

National Government Services Part A MR Department analyzes national and local data to identify possible improper payment for Medicare services. In an effort to reduce the Part A CERT error rate, the MR Department will be conducting a service specific post payment review of:

Edit Reason Code: 5ANLP
Bill Type = 81X, 82X

The primary focus of these audits will be to determine whether the medical necessity of the services billed is at the correct code per Medicare guidelines.

NGS has randomly selected claims billed for the services mentioned in JK for Part A providers in the states of New York, Connecticut, Massachusetts, Maine, New Hampshire, Vermont and Rhode Island.

If a claim is selected for review, the provider will receive an ADR letter. Providers with claims selected for review must submit the requested documentation within 45 days of the date of the ADR letter. Failure to submit the requested documentation in a timely manner may result in a denial of the billed services.

It is important to submit all documentation which supports the medical necessity of the mentioned services. The medical record must be legible and the name of the beneficiary, the date of service, and authenticated by an acceptable handwritten or electronic signature of the billing provider clearly identified. Please ensure all documentation to support medical necessity of the billed service is submitted for review. We will issue results upon completion of the post-payment review and offer education as needed.

Documentation Requirements

• Hospice election form
• Hospice certification/re-certification; include initial and all subsequent physician’s certifications. Ensure the applicable physician’s narrative summaries and face-to-face documentation are included
• Hospice initial admission assessment documentation
• Hospice POC, specific to beneficiary
• Documentation for all services provided, can include but is not limited to: nursing/therapy/social services/volunteer
• Complete general inpatient medical records
• Physician progress notes and orders
• Interdisciplinary team documentation
• Revocation of hospice election, if appropriate
• Documentation of any change in hospice status
• Hospice discharge documentation, if appropriate
• Please include the medical records / documentation for the previous 30 days from the claim's billed dates of service
• Documentation of required face-to-face encounters with the patient as described in the CMS IOM 100-02, Medicare Benefit Policy Manual, Chapter 9, Coverage of Hospice Services Under Hospital Insurance; Section 20.1, “Timing and Content of Certification”
• Medication administration record including dosing schedule. The medical record must include the following information:
  • The name of the drug or biological administered;
  • The route of administration;
  • The dosage (mg, mcg, cc or IU)
  • The duration of the administration
  • The medical record must clearly document the amount administered.
• Providers note: If there is an ABN on file, please submit the ABN with the above requested documentation.

Related Content

• CMS IOM Publication 100-02, Medicare Benefit Manual, Chapter 9, “Coverage of Hospice Services Under Hospital Insurance”
• Local Coverage Determination:  Hospice - Determining Terminal Status (L33393)
• YouTube Video: Medicare Signature Requirements by National Government Services

Updated 2/17/2021
Posted 2/12/2021