Home Health & Hospice Week

F2F, terminal prognosis are claim killers.

The latest numbers for Targeted Probe and Educate are grim for those providers who end up under the medical review program.

Out of 91 completed TPE probes of home health agencies from Jan. 1 to March 31, CGS reviewers found only four agencies compliant — 4 percent. Most of the probes were for Eligibility and Medical Necessity in the first round (edit 5A000), with 10 for Eligibility and Medical Necessity in the second round (edit 5B000), HHH Medicare Administrative Contractor CGS says in a new article on its website.

Problems with face-to-face physician encounter documentation continue to top the list of denial reasons at 30 percent. CGS reports.

Hospice providers fared better, but still saw dismal numbers. Out of 11 probes completed, CGS reviewers found only three compliant — 27 percent. Seven of the probes were for LOS with Non-On­cologic Diagnosis (edit 5D000), while four were for GIP LOC (edit 5D006).

Unsupported terminal prognosis and a missing or invalid physician narrative dominated the denial list at 47 percent and 17 percent, respec­tively. But invalid Notices of Election did make up 11 percent of denials, too.

Those denial reasons dovetail with the ones found by the Comprehensive Error Rate Testing contractor, MAC Palmetto GBA reports. Common hospice denial reasons under CERT include missing: a completed and signed election of benefits; a physician-signed certification or verbal certification; and face-to-face physician encounter clinical notes.

See more TPE details at https://cgsmedicare.com/hhh/pubs/news/2019/0519/cope12494.html.