Pre-Payment Review Results for Hospice Provisional Period of Enhanced Oversight on New Hospices in Texas for January to March 2024

Pre-Payment Review Results for Hospice Provisional Period of Enhanced Oversight (PPEO) on New Hospices in Texas for Targeted Probe and Educate (TPE) for January to March 2024

The Centers for Medicare & Medicaid Services (CMS) implemented the TPE process for PPEO on New Hospices in Texas. The reviews with edit effectiveness are presented here for states in Jurisdiction M. 

Cumulative Results

Probe One Findings 

Risk Category
The risk categories for Hospice PPEO on New Hospices in Texas are defined as:

Top Denial Reasons 

Denial Reasons and Prevention Recommendations

5FF36/5CF36 — Documentation Submitted Does Not Support Prognosis of Six Months or Less 

Reason for Denial
The claim has been fully or partially denied because the documentation submitted for review did not support prognosis of six months or less. 

How to Avoid This Denial

• Ensure a legible signature is present on all documentation necessary to support six-month prognosis 
•  Submit documentation for review to provide clear evidence the beneficiary has a six-month or fewer prognoses which supports hospice appropriateness at the time the benefit is elected and continues to be hospice appropriate for the dates of service billed
• Palmetto GBA has a Local Coverage Determination (LCD) for some non-cancer diagnoses. Submit documentation which supports the coverage criteria outlined in the policy. 
• If documenting weight loss to demonstrate a decline in condition, include how much weight was lost over what period of time, past and current nutritional status, current weight and any related interventions
• Document any comorbidity, which may further support the terminal condition of the beneficiary and the continuing appropriateness of hospice care

Resources

• CMS Internet-Only Manual (IOM), Pub. 100-02, Medicare Benefit Policy Manual, Chapter 9, Sections 10, 40 (PDF)
• CMS IOM, Pub. 100-04, Medicare Claims Processing Manual, Chapter 11, Section 10 (PDF)
   

5FFH9/5CFH9 – Physician Narrative Statement Not Present or Not Valid

Reason for Denial
The claim has been denied as the physician narrative statement is not present or not valid.

How to Avoid This Denial 

• The physician must include a brief narrative explanation of the clinical findings that supports a life expectancy of six months or less as part of the certification and recertification forms, or as an addendum to the certification and recertification forms
• If the narrative is part of the certification or recertification form, then the narrative must be located immediately prior to the physician’s signature 
• If the narrative exists as an addendum to the certification or recertification form, in addition to the physician’s signature on the certification or recertification form, the physician must also sign immediately following the narrative in the addendum 
• The narrative shall include a statement directly above the physician signature attesting that by signing, the physician confirms that he/she composed the narrative based on his/her review of the patient’s medical record or, if applicable his or her examination of the patient
• The narrative must reflect the patient’s individual circumstances and cannot contain check boxes or standard language used for all patients

Resources

• Title 42 Code of Federal Regulations (42 CFR), Section 418.22
• CMS IOM, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 9, Section 20.1 (PDF)
   

5FNER/5CNER — The Hospice Election Statement Does Not Meet Statutory/Regulatory Requirements

Reason for Denial
The claim has been fully or partially denied as the documentation submitted indicates that the statutory/regulatory requirements for the Hospice Election Statement were not met. 

How to Avoid a Denial
A Medicare beneficiary must complete an election statement before the Hospice Medicare Benefit can begin. The election statement must include the following items of information:

• Identification of the particular hospice that will provide care to the individual
• The individual’s or representative’s (as applicable) acknowledgment that the individual has been given a full understanding of hospice care, particularly the palliative rather than curative nature of treatment
• The individual’s or representative’s (as applicable) acknowledgment that the individual understands that certain Medicare services are waived by the election 
• The effective date of the election, which may be the first day of hospice care or a later date but may be no earlier than the date of the election statement. An individual may not designate an effective date that is retroactive.
• The individual’s designated attending physician (if any). Information identifying the attending physician recorded on the election statement should provide enough detail so that it is clear which physician or Nurse Practitioner (NP) was designated as the attending physician. This information should include, but is not limited to, the attending physician’s full name, office address, NPI number, or any other detailed information to clearly identify the attending physician.
• The individual’s acknowledgment that the designated attending physician was the individual’s or representative’s choice 
• For hospice elections beginning on or after October 1, 2020, the hospice must provide:
  1. Information on individual cost-sharing for hospice services
  2. Notification of the individual’s (or representative’s) right to receive an election statement addendum if there are conditions, items, services, and drugs the hospice has determined to be unrelated to the individual’s terminal illness and related conditions and would not be covered by the hospice
  3. Information on the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO), including the right to immediate advocacy and BFCC-QIO contact information
• The signature of the individual or representative
   

Resources

• CMS IOM, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 9, Sections 20.2.1.1, 20.1.2 (PDF)
• 42 CFR, Section 418.24
   

5FFH3/5CFH3 — No Certification for Dates Billed 

Reason for Denial
The claim has been fully or partially denied as documentation submitted for review did not include a certification covering all or some of the dates billed.

How to Avoid This Denial

• The hospice must obtain written certification of terminal illness for each benefit period
• All dates billed must be covered by a certification to be payable under the Medicare hospice benefit
• If more than one certification covers the dates of service in question, submit all the related certifications for review.

Resources

• CMS IOM, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 9, Sections 10, 20.1 (PDF)
• 42 CFR, Section 418.22
   

5CF92 — Hospice Continuous Care Hours Reduction

Reason for Denial
Hospice continuous care hours have been reduced to the routine care rate.

How to Avoid This Denial
Submit documentation to provider clear evidence the continuous care is being provided during a period of crisis.

• A period of crisis is defined as a time in which the beneficiary requires predominately nursing care to achieve palliation or management of acute medical symptoms
• For continuous care to be covered, care must be provided for a minimum of 8 hours during a 24-hour day which begins and ends at midnight
• The documentation submitted for review should reflect the care provided was predominately nursing care by either a registered nurse (RN) or licensed practical nurse (LPN), which means at least half of the hours of care were provided by an RN or LPN
• Ensure documentation submitted for review includes the number of hours of care provided by each discipline and it should match the number of units of continuous care hours billed

Resources

• CMS IOM, Pub. 100-04, Medicare Claims Processing Manual, Chapter 11, Section 30.1 (PDF)
• CMS IOM, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 9, Sections 10, 20.2, 40.2.1 (PDF) 
• 42 CFR, Section 418.20