01-036 Hospice Portfolio Notification of Medical Review

Noridian Healthcare Solutions, LLC (Noridian), as the Supplemental Medical Review Contractor (SMRC) for the Centers for Medicare and Medicaid Services (CMS), is conducting post-payment review of claims for Medicare hospice billed on dates of service (DOS) from January 1, 2018 through December 31, 2019. 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. The OIG also found that Medicare beneficiaries receiving hospice services in the Assisted Living Facility (ALF) setting had a higher prevalence of ill-defined diagnoses and an increased length of stay compared with beneficiaries receiving hospice services in other settings. In addition, the OIG found there are hospices that do not provide all levels of care, but instead are billing only for providing Routine Home Care (RHC) for all Medicare beneficiaries they serve.

CMS subsequently instructed Noridian to conduct data analysis and related medical review activities on hospice claims in the ALF setting to address the three areas of OIG concern referenced above for calendar year 2018 to be collectively known as Phase 2. Concurrently, Noridian will also conduct further data analysis and related medical review activities for hospices that do not provide all levels of care for calendar year 2019, to be known as Phase 3.

Reason for Review

In response to the OIG report, CMS instructed Noridian to conduct data analysis and related medical review activities on hospice claims in the ALF setting to address the three areas of OIG concern referenced abovefor calendar year 2018 to be collectively known as Phase 2. Concurrently, Noridian will also conduct data analysis and related medical review activities for hospices that do not provide all levels of care for calendar year 2019, to be known as Phase 3.

Claim Sample Detail

Project Phase Revenue Code HCPCS
Phase 2 and 3
  • 0651: RHC
  • 0652: CHC
  • Q5001: Home
  • Q5002: Assisted Living Facility
  • Q5003: Long Term Care or Non-skilled Nursing Facility
  • Q5009: Place not otherwise specified
  • Q5010: Hospice residential facility

Access related project details below.

Documentation Requirements

Below is a list of specific documentation requirements that will be included in each ADR to obtain the necessary documentation to perform the review. Documentation requested has been made specific to assist the provider in collecting and submitting pertinent information to decrease provider burden.

  1. Hospice election statement/Notice of Election (NOE) relevant to the DOS under review.
    1. Documentation to support whether the beneficiary’s chosen attending physician is a member of the hospice physician group, as applicable.
  2. Certification(s) of Terminal Illness (CTI) that cover the DOS under review.
    1. Face-to-Face Encounter Attestation statements as applicable to the certification period(s) during which the CHC care was provided.
  3. Hospice Plan-of-Care (POC) covering the dates of service, supporting any change(s) in Level-of-Care (LOC) including dates, reason for change, interventions, beneficiary’s response and collaboration between the hospice and other agencies and/or caregivers.
  4. Documentation to support the level of care provided for the DOS under review. This may include, but is not limited to, the following:
    1. Documentation to include, but not limited to visit notes, progress notes, consultation notes, assessments, treatment records, medication administration records (MAR) and discharge summary when applicable.
    2. Documentation to support duration of direct care provided and by which discipline(s) for any units of Continuous Home Care (CHC) billed, if applicable.
  5. Copies of any written notices provided to the beneficiary. For example, Advance Beneficiary Notice (ABN) of Noncoverage.
  6. Valid clinician signatures including signature attestations and signature logs, if applicable.

References/Resources

  • 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)(A). Exclusions from Coverage and Medicare as Secondary Payer
  • 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
  • Code of Federal Regulations (C.F.R.) Title 42, §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. Coverage of Hospice Services Under Hospital Insurance
  • 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 3.2.3.2. Timeframes for Submission
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8. No Response or Insufficient Response to Additional Documentation Requests
  • 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 (LCA) A52830 Hospice: Determining Terminal Status – Supplemental Instructions Article. Effective October 1, 2015
  • LCA A53054. Going Beyond Diagnosis: Hospice Cardiopulmonary Conditions. Effective October 1, 2015
  • LCA A53056. Hospice: Documenting Weight Loss for Beneficiaries with Non-Neoplastic Conditions. Effective October 1, 2015

Last Updated Oct 9, 2020