Palmetto to Conduct Hospice Specific Prepay Probe Review and CGS Expands Widespread Length of Stay Edits
November 1, 2013 12:18 PM
On October 30, 2013 two Medicare Administrative Contractors (MACs) announced actions impacting hospices. Palmetto GBA posted a notice 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 claims timeframe was not specified, but Palmetto GBA has identified top providers with a large number of beneficiaries receiving hospice services in Skilled Nursing Facilities. A service-specific probe will be initiated in J11 to look at beneficiaries with non-cancer diagnoses. Completed review results will be posted to the Palmetto GBA website. Individual providers with significant denials may be contacted for one-on-one education.
According to the CMS Program Integrity Manual, Chapter 3, service-specific prepayment probes are described as: “The MACs shall initiate targeted provider-specific prepayment review only when there is the likelihood of a sustained or high level of payment error. MACs are encouraged to initiate targeted service-specific prepayment review to prevent improper payments for services identified by CERT or Recovery Auditors as problem areas.”
On the same date, CGS announced that it is going to expand its widespread hospice length of stay edits by doing the following:
Implement a new widespread edit, 5118T, 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, TS, and WV.
Discontinue widespread edit 5048T (selects hospice claims with a length of stay of 999 days or more) once the new edit 5118T is implemented.
Expand parameters for edit 5091T to include any non-oncologic diagnosis code. Edit 5091T selects claims when the beneficiary resides in a nursing home, the hospice length of stay is greater than 180 days, and the principal diagnosis is debility, unspecified. The reason for expanding the diagnosis codes on this edit is the high denial rate of 61%.
More information on the Palmetto GBA review can be found here and information for the CGS expansion of hospice edits can be found here.
What You Should Do:
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 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 (partial or full) can be appealed within 120 days of determination (date on remittance advice).
NAHC and HAA will continue to monitor these situations and provide you with updated data.