UPDATE: Palmetto to Conduct Hospice-specific Prepay Probe Review
November 21, 2013 10:56 AM
As reported in the November 1, 2013 NAHC Report, Palmetto GBA notified providers that it will perform 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 Q5004 location code is used when a hospice beneficiary is residing in a skilled nursing facility and the facility staff is providing skilled care to the patient, i.e. hospice general inpatient level of care.
Palmetto has identified 13 providers with a large number of beneficiaries receiving hospice services billed with the Q5004 location code. In accordance with CMS requirements, the service-specific probe will encompass 100 claims from these 13 identified providers. This is a prospective review. Based on the results, Palmetto may or may not initiate further probes/edits for these providers and/or other hospice providers.
What You Should Do Now:
Hospices should check the FISS system, ideally on a daily basis but not less than weekly, for any claims in the S B6001 status that indicates there is an additional development request (ADR) on the claim. If there is an ADR, hospices must respond no later than 30 days after the request date. Records can be mailed or faxed. Any denials can be appealed within 120 days.