Service Specific Post Payment Medical Review Summary Results of Hospice Services with General Inpatient Care, Date of Service 3/1/2020 and After

Table of Contents

• Service Specific Post Payment Medical Review Summary Results of Hospice Services with General Inpatient Care, Date of Service 3/1/2020 and After
• Findings
• Top Denials
• Related Content

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Service Specific Post Payment Medical Review Summary Results of Hospice Services with General Inpatient Care, Date of Service 3/1/2020 and After

On 7/6/2021, 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: 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 3/1/2020 and after.

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 Types	Error Rate Calculations
# of ADRs Sent	50
# Claims Reviewed	49
# Claims Denied	33
Claims Denial/Error Rate (CER)	66.00%
Charges/Payment Error Rate (PER)	43.77%

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Top Denials:

• Reason Code 55H1M: According to Medicare hospice requirements, the documentation does not support the GIP level of care.
  • 19 claims denied.
  • For example, the beneficiary’s status did not support frequent changes in medications or care plan.
• Reason Code 55H1K: No Documentation to support services as billed
  • Three claims denied.
  • Example: No documentation of the physician visit billed
• Reason Code 5H1Y: Physician Narrative Statement not present.
  • Three 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.
• Reason Code 55H1F: No Certification Present in the Documentation Submitted for the dates billed.
  • Three claims denied
  • For example: certification not sent

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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
• LCD: Hospice – Determining Terminal Status (L33393)
• YouTube Video : Medicare Signature Requirements by National Government Services