Medical Review

Service Specific Post-Payment Audits of Hospice GIP Care

Table of Contents

  • Service Specific Post-Payment Audits of Hospice GIP Care
  • Overview
  • Documentation Requirements
  • Related Content
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    Service Specific Post-Payment Audits of Hospice GIP Care

    Please note: Some of the TPE reviews will involve claims that have already been processed (postpayment). The notification letter for postpayment TPE reviews will include a listing of all the claims being selected. TPE reviews that are being done for new claim submissions (prepayment) will include a notification letter followed by separate ADRs for each claim involved.

    Prior to this restart of TPE reviews, NGS had been conducting service specific post payment reviews. Providers should continue responding to these service specific postpayment ADR requests that have already been issued. Providers are encouraged to review the Medical Review Focus Areas to learn about what services are being selected, what documentation will be requested, and more details on these service specific post-payment reviews.

    Edit Reason Code: 5CPGP/5WPGP
    Bill Type = 81X, 82X
    Revenue Code: 0656, 7 or more days

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    Overview

    When a claim is randomly selected for review, the provider will receive an ADR letter. We must receive the medical records necessary to support the billed services within 45 days of the date of the ADR letter. Failure to submit the requested documentation in a timely manner may result in denial of the billed service. All documentation must be legible and authenticated by an acceptable handwritten or electronic signature. We will issue results upon completion of the post-payment review and offer education as needed.

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    Documentation Requirements

    • Notice of election/signed election statement by the beneficiary
    • Initial and subsequent physician’s certifications, including applicable physician’s narrative summaries
    • Interdisciplinary group notes
    • Complete general inpatient medical records
    • Hospice plan of care for beneficiary
    • Nurses notes and initial assessment, if applicable
    • Physician progress notes and orders
    • All other caregiver notes
    • Documentation to support the face-to-face encounter
    • If there is an ABN on file, please include a copy of the signed and dated ABN of noncoverage to the beneficiary.

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    Related Content

    Posted 8/14/2020

    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.

    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.