Eli's Hospice Insider

Medical reviewers target nursing home patients, long LOS, non-cancer diagnoses.

If you thought medical review of your hospice claims was high already, just wait. Two HHH Medicare Administrative Contractors have announced new and expanded edits of hospice claims.

HHH MAC CGS is “implementing a new widespread edit that will select claims with a length of stay between 150 days and 365 days for providers that bill to CGS within the states of NH, ID, GA, UT, CO, DE, MO, AL, AR, KS, TX, and WV.” Medicare data recently indicated these states had higher hospice spending in 2012, CGS indicates.

CGS will also continue a widespread edit that targets hospice patients that reside in nursing homes, have stays greater than 180 days, and have a principal diagnosis of debility, unspecified, the MAC says.” Last quarter, this edit had the highest denial rate of all four widespread hospice edits at 61 percent,” CGS explains.” The top denial reason for this edit continues to be 5PTER, six-month terminal prognosis not supported.”

Don’t miss: However, CMS is expanding the edit to nursing home residents with stays over 180 days with any “non-oncologic” diagnosis, CGS says.

Meanwhile, HHH MAC Palmetto GBA is also focusing on nursing home patients with non-cancer diagnoses. “Palmetto GBA will be performing a service-specific prepay probe review on hospice claims with non-cancer diagnoses, billed with place of service Skilled Nursing Facility, HCPCS code Q5004,” the MAC says on its website.

Targets: “Palmetto GBA has identified top providers with a large number of beneficiaries receiving hospice services in Skilled Nursing Facilities,” the MAC explains. “A service-specific probe will be initiated in J11 to look at beneficiaries with non-cancer diagnoses.”