Pre-Payment Review Results for Hospice General Inpatient Care for January to March 2025

Pre-Payment Review Results for Hospice General Inpatient (GIP) Care for Targeted Probe and Educate (TPE) for January through March 2025

The Centers for Medicare & Medicaid Services (CMS) implemented the TPE process for Hospice GIP Care. The reviews with edit effectiveness are presented here for states in Jurisdiction M.

Cumulative Results

Probe One Findings

Probe Two Findings

Risk Category

The risk categories for Hospice GIP Care are defined as:

Figure 1. Risk Category for Hospice GIP Care.

Top Denial Reasons and Recommendations

Denial Reasons and Prevention Recommendations

5CF91 — Hospice General Inpatient Reduction — Services Not Reasonable and Necessary

Reason for Denial
The hospice services billed for general inpatient care days were not covered, as submitted documentation did not support medical necessity. Therefore, the general inpatient care days were reduced to routine care days.

How to Avoid This Denial
The hospice benefit allows for general inpatient care services if the hospital stay is reasonable and necessary. Documentation should include the following:

• Name of the contract facility in which the patient is receiving general inpatient care
• Explanation for admission to the inpatient facility
• Hospice interdisciplinary notes during the general inpatient stay and the physician’s discharge summary
• Documentation of the patient’s condition during the inpatient stay

Hospitalization must be on a short-term basis and must be related to complications attributable to the terminal diagnosis such as pain control or symptom management which cannot be provided in other settings. In order to avoid denials for this reason, the documentation submitted must include the following:

• Need for pain control or symptom management that is not feasible in other settings
• Skilled care required when home support has broken down and it is no longer feasible to furnish needed care in the home setting
• Patient’s need for medication adjustment, observation, or other stabilizing treatments, which cannot be furnished in home

References

• CMS Internet-Only Manual (IOM), Pub. 100-02, Medicare Benefit Policy Manual, Chapter 9, Section 40.1.5 (PDF)
• CMS IOM, Pub. 100-04, Medicare Claims Processing Manual, Chapter 11, Section 30.1 (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

References

• 42 Code of Federal Regulations (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 This 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:
  • Information on individual cost-sharing for hospice services
  • 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
  • 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

References

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

5FFH6/5CFH6 — Initial Certification Not Timely

Reason for Denial
The claim has been fully or partially denied, as the documentation submitted for review did not include an initial certification signed timely by the medical director and attending physician (if any).

How to Avoid This Denial

• For the first 90-day period of hospice coverage, the hospice must obtain, no later than two calendar days after hospice care is initiated, (that is by the end of the third day), oral or written certification of the terminal illness by the medical director of the hospice or the physician member of the hospice interdisciplinary group and the beneficiary’s attending physician (if the beneficiary has an attending physician)
• Written certification must be on file in the hospice beneficiary’s record prior to submission of a claim to the Fiscal Intermediary
• If these requirements are not met, the payment begins with the day of certification
• The initial certification may be completed up to 15 days before hospice care is elected
• If the attending physician and the medical director are the same, the certification must clearly identify this information

References

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

5FFNP/5CFNP — No Plan of Care

Reason for Denial 
The claim has been fully or partially denied as documentation submitted for review did not include a plan of care (POC) for all or some of the dates billed. Claims with dates of service beginning July 19, 2010, require that a valid POC be included as part of the medical review process according to Change Request 6982.

How to Avoid This Denial

• The hospice must submit a POC for dates of service billed when responding to additional documentation request (ADR)
• All dates billed must be covered by a POC to be payable under the Medicare hospice benefit
• If more than one POC covers the dates of service in question, submit all the related plans of care for review 
• The POC must contain certain information to be considered valid. This includes: 
  • Scope and frequency of services to meet the beneficiary’s/family’s needs
  • Beneficiary specific information, such as assessment of the beneficiary's needs, management of discomfort and symptom relief
  • Services that are reasonable and necessary for the palliation and management of the beneficiary’s terminal illness and related conditions
• The POC must specify the hospice care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment
• All hospice care and services must follow an individualized written POC
• The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) must review, revise and document the individualized plan as frequently as the patient's condition requires, but no less frequently than every 15 calendar days. A revised POC must include information from the patient's updated comprehensive assessment and must note the patient's progress toward outcomes and goals specified in the POC.

References

• 42 CFR, Sections 418.56 and 418.20
• CMS IOM, Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4 (PDF)
   

Education
Palmetto GBA offers providers selected for TPE an individualized education session to discuss each claim denial. This is an opportunity to learn how to identify and correct claim errors. A variety of education methods are offered such as webinar sessions, web-based presentations or teleconferences. Other education methods may also be available. Providers do not have to be selected for TPE to request education. If education is desired, please complete the Education Request Form (PDF).

Next Steps
Providers found to be non-compliant (major risk category/denial rate of 21–100 percent) at the completion of TPE Probe 1 will advance to Probe 2, and providers found to be non-compliant (major risk category/denial rate of 21–100 percent) at the completion of TPE Probe 2 will advance to Probe 3 of TPE after at least 45 days from completing the 1:1 post-probe education call date.