01-013 Hospice Portfolio Notification of Medical Review

Noridian Healthcare Solutions, LLC, as the Supplemental Medical Review Contractor (SMRC) for the CMS, is conducting post-payment review of claims for general inpatient hospice billed on dates of service from January 1, 2018, through December 31, 2018. This notification includes the reasons for the review, documentation that will be requested in the Additional Documentation Request (ADR) letter and resources providers/suppliers may wish to consult when submitting claims.

Background

The Office of Inspector General (OIG) under report OEI-02-16-00570, Vulnerabilities in the Medicare Hospice Program Affect Quality Care and Program Integrity: An OIG Portfolio, dated July 2018, found that hospices frequently bill Medicare for a higher level of care than the beneficiary needs. Hospices inappropriately billed General Inpatient Care (GIP) stays when the beneficiary did not have uncontrolled pain or unmanaged symptoms. The report also identified certain hospices that engage in practices or have characteristics that raise concerns. These concerns include hospices that target beneficiaries in the Assisted Living Facility (ALF) setting, those with a high percentage of beneficiaries with diagnoses that require less complicated care and those that do not provide all levels of hospice care.

The Centers for Medicare and Medicaid Services (CMS) instructed Noridian Healthcare Solutions, LLC (Noridian) as the current SMRC, to conduct additional data analysis and related medical review activities on GIP hospice claims in the Skilled Nursing Facility (SNF) setting to ensure the services rendered were paid appropriately. Medical review activities will also be performed that focus on services provided in the ALF setting. The selection of claims for this review was determined by the SMRC through data analysis.

Reason for Review

In response to the OIG report, the CMS tasked Noridian, as the SMRC, to conduct medical review. The SMRC will perform review activities on GIP hospice claims to ensure the services were paid appropriately in the SNF setting. Phase two of the project will focus on services provided in the ALF setting.

Claim Sample Detail

Project Phase Revenue Code HCPCS
Phase 1 0656 Q5004: Skilled Nursing Facility (SNF)

Access related project details below.

Documentation Requirements

Phase one:

  • Hospice election statement/Notice of Election (NOE) relevant to the date of service (DOS) under review
  • Documentation to support whether, or not the beneficiary’s chosen attending physician is a member of the hospice physician group, as applicable
  • Certification(s) of Terminal Illness (CTI) that cover the DOS under review
  • Face-to-Face Encounter Attestation statements as applicable to the certification period(s) during which the GIP care was provided
  • Documentation to support the GIP stay for pain control and/or symptom management indicating the interventions performed could not be feasibly provided in any other setting for the DOS under review. This may include, but is not limited to, the following:
    • Hospice Plan of Care (POC) covering the GIP stay supporting the change in Level of Care (LOC) including dates, reason for GIP, interventions, beneficiary’s response and collaboration between the hospice and skilled nursing facility (SNF) teams
  • Clinical documentation to include, but not limited to, admission history and physical, progress notes, consultation notes, nursing assessments, treatment records, wound care documentation, medication administration records (MAR) and discharge summary
  • Hospice team documentation to include, but not limited to, visits, assessments and discharge planning for the DOS under review
  • Documentation indicating the affiliation (Hospice/Non-Hospice) of the physician(s) documenting in the beneficiary’s records
  • Copies of any written notices provided to the patient. For example, Advance Beneficiary Notice (ABN) of Noncoverage
  • Valid clinician signatures including signature attestations and signature logs, if applicable

References/Resources

Phase One:

  • Social Security Act (SSA), Title XVIII, §1812(a)(4), (a)(5), (d)(1). Scope of Benefits
  • SSA, Title XVIII, §1814(a)(7). Conditions of and Limitations on Payment for Services – Requirement of Requests and Certifications
  • SSA, Title XVIII, §1815(a), (e)(2)(D). Payment to Providers of Services
  • SSA, Title XVIII, §1833(e). Payment of Benefits
  • SSA, Title XVIII, §1861(dd). Definitions of Services, Institutions, Etc. – Hospice Care
  • SSA, Title XVIII, §1862 (a)(1)(c). Exclusions from Coverage and Medicare as Secondary Payer
  • SSA, Title XVIII, §1879(a)(1), (g)(2). Limitation on Liability of Beneficiary where Medicare Claims are Disallowed
  • 42 C.F.R. 424.5(a)(6). Conditions for Medicare Payment – Basic Conditions, Sufficient Information
  • 42 C.F.R. 418, Subpart A. General Provisions and Definitions
  • 42 C.F.R. 418, Subpart B. Eligibility, Election and Duration of Benefits
  • 42 C.F.R. 418, Subpart F. Covered Services
  • 42 C.F.R. 418, Subpart G. Payment for Hospice Care
  • CMS Internet Only Manual (IOM), Publication 100-01, Medicare General Information, Eligibility and Entitlement Manual, Chapter 4, Section 60. Certification and Recertification by Physicians for Hospice Care
  • CMS IOM, Publication 100-01, Medicare General Information, Eligibility and Entitlement Manual, Chapter 5, Section 60. Hospice Defined
  • CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 9, Section 10. Requirements—General
  • CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 9, Section 20. Certification and Election Requirements
  • CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 9, Section 40. Benefit Coverage
  • CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 9, Section 50. Limitation on Liability for Certain Hospice Coverage Details
  • CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 11. Processing Hospice Claims
  • CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 30, Section 50. Form CMS-R-131 Advance Beneficiary Notice of Noncoverage (ABN)
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4. Signature Requirements
  • Local Coverage Determination (LCD) L33393: Hospice – Determining Terminal Status. Effective October 1, 2015
  • LCD L34538: Hospice Determining Terminal Status. Effective October 1, 2015
  • LCD L34544: Hospice – Liver Disease. Effective October 1, 2015
  • LCD L34547: Hospice – Neurological Conditions. Effective October 1, 2015
  • LCD L34548: Hospice Cardiopulmonary Conditions. Effective October 1, 2015
  • LCD L34558: Hospice The Adult Failure to Thrive Syndrome. Effective October 1, 2015
  • LCD L34559: Hospice – Renal Care. Effective October 1, 2015
  • LCD L34566: Hospice – HIV Disease. Effective October 1, 2015
  • LCD L34567: Hospice Alzheimer’s Disease & Related Disorders. Effective October 1, 2015
  • Local Coverage Article A52830 Hospice: Determining Terminal Status – Supplemental Instructions Article. Effective October 1, 2015
  • Local Coverage Article A53054 Going Beyond Diagnosis: Hospice Cardiopulmonary Conditions. Effective October 1, 2015
  • Local Coverage Article A53056 Hospice: Documenting Weight Loss for Beneficiaries with Non-Neoplastic Conditions. Effective October 1, 2015
  • MLN Matters SE1628: Documentation Requirements for the Hospice Physician Certification/Recertification

Last Updated Aug 1, 2019