Home Health & Hospice Week

MACs reveal new medical review topics.

Medical review resumption is proceeding, despite COVID-19 burdens.

The three HHH Medicare Administrative Contractors have released information on their medical review topics in light of the Medicare’s program decision to resume medical review this month.

Palmetto GBA: Palmetto lists “Home Health Services for Eligibility and Medical Necessity” as its sole home health active review topic in an Aug. 19 post, with further elaboration that it’s “Review of inpatient claims submitted for Home Health Services for Eligibility and Medical Necessity.”

On the hospice side, Palmetto lists “General Inpatient Care (GIP),” further detailing that involves “Review of inpatient claims for Inpatient Hospice Care greater than or equal to 7 days for Revenue Code 656 and place of service codes Q5004–QA5009.”

National Government Services: NGS identifies its home health edit only as “Home Health PDGM (Edit 5AAGP),” noting that claims will be “randomly selected for review.”

For hospice, NGS will review claims with “Length of Stay Over 730 Days (Edit 5ANKP),” according to the MAC’s website.

CGS: CGS also lists one active home health topic, “Home Health Medical Necessity” with reason code 5L000. “This review selects any home health claim with 2 to 6 visits and a diagnosis code of I11.0, Z46.6, J44.1, I10, J44.9, G20, I25.10, N39.0, J18.9, or I87.2 submitted with dates of service prior to March 1, 2020.”

How it works: CGS doesn’t have a hospice topic listed, noting only that it will be “coming soon” on the medical review webpage.

“We must receive the medical records necessary to support the billed services within 45 days of the date of the ADR letter,” NGS reminds providers. “Failure to submit the requested documentation in a timely manner may result in denial of the billed service.”

Tip: “We recommend you include the original ADR with your response,” Palmetto says in an article about responding to the new postpayment reviews.

“Providers should expect to see ADRs this week if they’ve not already,” says the National Association for Home Care & Hospice on its member listserv.