- Medical Review
- Medical Review Focus Areas
- Service Specific Post-Payment Audits of Home Health PDGM Bills
- Service Specific Post-Payment Audits for Hospice Length of Stay > 730 Days
- Service Specific Post Payment Review of Psychotherapy, 60 Minutes with Patient – CPT 90837
- Service Specific Post Payment Review of Ambulance Transport and Mileage When Billed With Modifiers RJ, JR, RG, GR, NJ, JN, NG, GN
- Service Specific Post-Payment Audits of Home Health Value Code 17 Bills
- Announcing Service Specific Post-Payment Audits of Hyperbaric Oxygen (HBO) Services for J6 A Regions: IL, WI, and MN
- Service Specific Post-Payment Medical Review Notice Home Health PDGM (Edit 5AAGP)
- Service Specific Post Payment Review of Botulinum Injection, onabotulinumtoxina, 1 Unit – CPT J0585
- Service Specific Post Payment Review of Floweramnioflo, 0.1 CC – CPT Q4177
- Service Specific Post Payment Review of Grafix Prime (CPT Q4133)
- Service Specific Post Payment Review of Nonemergency Ambulance Transport and Mileage
- Service Specific Post Payment Review - Hospice GIP Services Over 7 Days (5ANLP) for JK A Regions: NY/CT, MA, ME, NH/VT and RI
- Service Specific Post Payment Review of Home Health Homebound Criteria (Edit 5AAHP)
- Service Specific Post Payment Review of Fluoroscopic Guidance for Needle Placement - CPT 77002
- Service Specific Post Payment Review of Computed Tomography, Abdomen and Pelvis with Contrast Material(s) - CPT 74177
- Service Specific Post Payment Review of Darbepoetin Alfa Injection, 1 microgram (Non-ESRD Use)
- Service Specific Post Payment Review of Therapeutic Procedure, 1 or More Areas, Each 15 Minutes; Aquatic Therapy With Therapeutic Exercise – CPT 97113
- Service Specific Post Payment Medical Review Summary Results of Hospice Services with Length of Stay > 730 Days
- Service Specific Post Payment Medical Review Summary Results of Home Health Value Code 17 Bills
- Review Results For Service Specific Postpayment Review of Psychotherapy, 60 Minutes With Patient
- Service Specific Post-Payment Medical Review Notice Hospice with Length of Stay over 730 Days (Edit 5ANKP)
- Service Specific Post-Payment Audits of Hospice GIP Care, DOS 3/1/2020 and After
- Service Specific Post-Payment Audits of Home Health LUPA Claims
- Service Specific Post Payment Review of Debridement, Subcutaneous Tissue (Includes Epidermis and Dermis, If Performed); First 20 Square Centimeters or Less– CPT 11042
- Service Specific Post-Payment Review of Tangential Biopsy of Skin-Single Lesion CPT 11102 with Destruction-Premalignant Lesion-First Lesion CPT 17000
- Service Specific Post Payment Review Summary Results – Home Health PDGM Bills (Edit 5AAGP)
- Review Results for Service Specific Post-Payment Review of Artacent Wound, per Square Centimeter - CPT Q4169
- Review Results for Service Specific Post-Payment Review of Q4133 - Grafix Prime
- Announcing Service Specific Post-Payment Audits of Group Psychotherapy Services for J6 A Regions: IL, WI and MN
- Service Specific Post Payment Medical Review Summary Results of Hospice Services with GIP > 7 Days
- Service-Specific Postpayment Medical Review Summary Results of Home Health PDGM Bills
- Review Results for Service Specific Post-Payment Review of Hyaluronan or Derivative - CPT J7326
- Review Results for Service Specific Post Payment Review of Hyaluronan or Derivative – CPT J7327
- Review Results for Service Specific Post-Payment Review of Fluoroscopic Guidance for Needle Placement
- J6_B_Review Results for Service Specific Post-Payment Review of J0585 – Botulinum Injection, Onabotulinumtoxina
- Review Results for Service Specific Post-Payment Review of Computed Tomography, Abdomen And Pelvis; With Contrast Material(s)
- Review Results for Service Specific Post-Payment Review of Therapeutic Procedure, 1 or More Areas, Each 15 Minutes; Aquatic Therapy with Therapeutic Exercise - CPT 97113
- Review Results for Service Specific Post Payment Review of Floweramnioflo
- Review Results for Service Specific Postpayment Review of Tangential Biopsy of Skin; Single Lesion CPT 11102 with Destruction, Premalignant Lesion; First Lesion CPT 17000
- Review Results for Service Specific Post-Payment Review of Darbepoetin Alfa Injection (Non-ESRD Use)
- Service Specific Post-Payment Review Summary Results – Home Health Homebound Criteria (Edit 5AAHP)
- Service Specific Post-Payment Review Summary Results – Hospice GIP Services Greater than 7 Days (Edit 5ANLP)
- Service Specific Post Payment Medical Review Summary Results of Hospice Services with General Inpatient Care, Date of Service 3/1/2020 and After
- Service Specific Post Payment Medical Review Summary Results of Home Health Low Utilization Payment Adjustment Claims
- Announcing Service Specific Post-Payment Audits of Individual Psychotherapy Services for J6 A Regions: IL, WI and MN
- Review Results for Service Specific Post Payment Review of Debridement, Subcutaneous Tissue (Includes Epidermis and Dermis, if Performed); First 20 Square Centimeters or Less – CPT 11042
- Service Specific Post Payment Review of Artacent Wound, Per Square Centimeter - CPT Q4169
- Service Specific Post-Payment Audits of Hospice GIP Care
- Service Specific Post Payment Review of Hyaluronan or Derivative - HCPCS J7326, J7327
- Skilled Nursing Facility Education Center
Service Specific Post Payment Medical Review Summary Results of Hospice Services with GIP > 7 Days
Table of Contents
- Service Specific Post Payment Medical Review Summary Results of Hospice Services with GIP > 7 Days
- Findings
- Top Denials
- Related Content
Service Specific Post Payment Medical Review Summary Results of Hospice Services with GIP > 7 Days
On 8/14/2020, 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 Home Health 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: 5CPGP/5WPGP
- Bill Type: 81X, 82X
- Service Description: GIP > 7 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.
Findings
| Error Rate Types | Error Rate Calculations |
|---|---|
| Number of ADRs Sent | 159 |
| Number of Claims Reviewed | 149 |
| Number of Claims Denied | 82 |
| Claims Denial/Error Rate (CER) | 51.57% |
| Charges/Payment Error Rate (PER) | 39.15% |
Top Denials
- Reason Code 55H1M: According to Medicare hospice requirements, the documentation does not support the GIP level of care.
- 41 claims denied.
- For example, the beneficiary’s status did not support frequent changes in medications or care plan.
- Reason Code 56900: No Response from medical record request.
- 10 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 due 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 55H1R: Notice of Election is invalid because it doesn’t meet Statutory/Regulatory requirements
- 6 claims denied.
- Example: The election did not state care is palliative, not curative.
- Reason Code 5H1Y: Physician Narrative Statement not present.
- 6 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 directly above the physician’s signature and should be completed by the certifying physician.
Related Content
- CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 9, “Coverage of Hospice Services Under Hospital Insurance”
- CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 11, Processing Hospice Claims
- 42 CFR 418.22
- Local Coverage Determination (LCD): Hospice – Determining Terminal Status (L33393)
- YouTube Video : Medicare Signature Requirements by National Government Services
Posted 8/30/2021
Targeted Probe and Educate Manual
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Targeted Probe and Educate Manual
The preferred method to submit Medical Records is NGSConnex:
Visit our Contact Us page for other methods of submission.
Targeted Probe and Educate Manual
The preferred method to submit Medical Records is NGSConnex:
Visit our Contact Us page for other methods of submission.
Targeted Probe and Educate Manual
The preferred method to submit Medical Records is NGSConnex:
Visit our Contact Us page for other methods of submission.
Targeted Probe and Educate Manual
The preferred method to submit Medical Records is NGSConnex:
Visit our Contact Us page for other methods of submission.
Targeted Probe and Educate Manual
The preferred method to submit Medical Records is NGSConnex:
Visit our Contact Us page for other methods of submission.
Targeted Probe and Educate Manual
The preferred method to submit Medical Records is NGSConnex:
Visit our Contact Us page for other methods of submission.
Targeted Probe and Educate Manual
The preferred method to submit Medical Records is NGSConnex:
Visit our Contact Us page for other methods of submission.