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Medicare Administrative Contractors Announce Intent to Review Hospice Claims

Posted on November 8, 2013 in Long-Term Care, Home Health & Hospice

Written by: Ruff, Anne M.

On October 30, two Medicare Administrative Contractors, Palmetto GBA and CGS, announced their intent to focus on certain hospice claims for patients located in Skilled Nursing Facilities (“SNFs”).

Palmetto GBA announced that it has identified top providers with a large number of beneficiaries receiving hospice services in SNFs, and it intends to initiate a service-specific investigation of claims for beneficiaries with non-cancer diagnoses.  While the claim’s timeframe is unknown, the investigation will be initiated in Jurisdiction 11, which covers home health and hospice services in Alabama, Arkansas, Florida, Georgia, Illinois, Indiana, Kentucky, Louisiana, Mississippi, New Mexico, North Carolina, Ohio, Oklahoma, Tennessee and Texas.  Once complete, review results will be posted on the Palmetto GBA website and individual providers may be contacted for one-on-one education.

Similarly, CGS announced its intent to expand its existing hospice length of stay edits. Currently, the CGS Medical Review Department uses established edits to evaluate and select the most vulnerable claims.  CGS currently uses edit 5048T to select hospice claims with a length of stay 999 days or more but has decided to phase out edit 5048T in favor of a new edit that will identify claims earlier.  New edit 5118T will select claims with a length of stay between 150 and 365 days for providers that bill to CGS within the states of New Hampshire, Idaho, Georgia, Utah, Colorado, Delaware, Missouri, Alabama, Arkansas, Kansas, Tennessee and West Virginia. Widespread edit 5048T will be discontinued once edit 5118T is implemented.

In addition, CGS proposes to expand edit 5091T, which selects claims for beneficiaries who (i) reside in an SNF; (ii) have a hospice length of stay greater than 180 days; and (iii) have a principal diagnosis of debility, unspecified, to include any non-oncologic diagnostic code.  CGS noted the expansion was due to CMS clarification in the 2014 Hospice Final Rule on principal diagnosis coding, which states claims identifying “debility” as the principal diagnosis will be returned for more definitive coding, and edit 5091T’s high denial rate was based on failure to demonstrate the six-month terminal prognosis.

Providers should consider reviewing their censuses to identify numbers of patients in SNFs and numbers of patients with non-cancer diagnoses.  This will allow providers to identify what level of scrutiny they might expect from this edit.  Providers who identify these patients should consider auditing charts to identify whether the documentation in the patients’ charts supports the provision of Medicare hospice services.

Going forward, hospice providers who provide services to non-cancer patients in facilities will need to ensure medical records contain sufficient documentation to demonstrate the illness is terminal and progressing in a manner that a physician would reasonably have concluded that the beneficiary’s life expectancy is six months or less. Documentation is especially essential for patients that remain on the hospice benefit for an extended length of time or for patients that have chronic illnesses or general decline. These diagnoses may not be sufficient to support a six-month or less life expectancy, and documentation will be necessary to demonstrate why the patient is hospice appropriate.

This action means that providers with patients in facilities that have non-cancer diagnoses should anticipate increased scrutiny as a result of these actions.   This does not mean that non-cancer patients in facilities are not appropriate, but rather providers will have to be very careful to document that these patients meet the Medicare Hospice eligibility criteria.

Should you have any questions, please contact Todd Selby at 317.977.1440 or tselby@hallrender.com, Robert Markette at 317.977.1454 or rmarkette@hallrender.com, Anne Ruff at 317.977.1450 or aruff@hallrender.com or your regular Hall Render attorney.