Medical Review

Service Specific Post Payment Medical Review Summary Results of Hospice Services with Length of Stay > 730 Days

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Service Specific Post Payment Medical Review Summary Results of Hospice Services with Length of Stay > 730 Days

On 12/7/2020, National Government Services Part A MR Department initiated a service specific post-payment review of randomly selected claims billed for the following services mentioned in J6 for hospice providers in the states of New York, New Jersey, Puerto Rico, U.S. Virgin Islands, Michigan, Minnesota, Wisconsin, Alaska, American Samoa, Arizona, California, Guam, Hawaii, Idaho, Nevada, Northern Mariana Islands, Oregon and Washington.

  • Edit Reason Code: 5CSLP/5WSLP
  • Bill Type: 81x, 82x
  • Service Description: LOS > 730 days

The results of this review provide a summary of claims with dates of service of 1/1/2019 through 2/29/2020.

Note: Results are for post-payment medical record determinations only and do not include appeal results for overturns and decision reversals. Claims Error rate includes claims denied 56900 and not reviewed.

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Findings

Error Rate Description Error Rate Calculations
Number of ADRs Sent 187
Number of Claims Reviewed 169
Number of Claims Denied 118
Claims Denial/Error Rate (CER) 63.10%
Charges/Payment Error Rate (PER) 64.10%

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Top Denials

  • Reason Code 55H1L: According to Medicare hospice requirements, the information provided does not support that the beneficiary’s illness is terminal.
    • 57 claims denied
    • For example, the beneficiary’s overall status was very similar to admission status; since the documentation showed no decline in beneficiary’s status, therefore, the terminal prognosis of six months or less is not supported.
  • Reason Code 55H1S: Face-to-Face Encounter Requirements not met.
    • 22 claims denied
    • Example: Documentation of the face-to-face encounter was not included in the record.
  • Reason Code 56900: No Response from medical record request.
    • 18 claims denied
    • Reason code 56900 will occur when providers do not respond to an ADR. This reason code can and should be prevented. When providers receive an ADR, respond according to the date listed in the ADR. Providers should start gathering the documentation requested immediately. This will ensure that there is adequate time to gather all of the requested supporting documentation that so that the timeframe for submitting the information can be met. Depending on the information requested, providers may have to go outside of their facilities to get the supporting documentation and this may require time to receive from that entity.
  • Reason Code 5H1Y: Physician Narrative Statement not Present.
    • 9 claims denied
    • For example, the narrative statement is missing or does not include information to support the rationale for a six-month or less prognosis. In addition, the attestation must be above the physician’s signature and should be completed by the certifying physician.

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Targeted Probe and Educate Manual

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Helpful Resources

Targeted Probe and Educate Manual

The preferred method to submit Medical Records is NGSConnex:

Visit our Contact Us page for other methods of submission.

Helpful Resources

Targeted Probe and Educate Manual

The preferred method to submit Medical Records is NGSConnex:

Visit our Contact Us page for other methods of submission.

Helpful Resources

Targeted Probe and Educate Manual

The preferred method to submit Medical Records is NGSConnex:

Visit our Contact Us page for other methods of submission.

Helpful Resources

Targeted Probe and Educate Manual

The preferred method to submit Medical Records is NGSConnex:

Visit our Contact Us page for other methods of submission.

Helpful Resources

Targeted Probe and Educate Manual

The preferred method to submit Medical Records is NGSConnex:

Visit our Contact Us page for other methods of submission.

Helpful Resources

Targeted Probe and Educate Manual

The preferred method to submit Medical Records is NGSConnex:

Visit our Contact Us page for other methods of submission.

Helpful Resources

Targeted Probe and Educate Manual

The preferred method to submit Medical Records is NGSConnex:

Visit our Contact Us page for other methods of submission.