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Friday, June 24, 2016

Hospice Medical Review Top Denial Reason Codes:


We encourage all providers to review this information when filing claims to prevent denials and to ensure their claims are processed timely.

The claim has been fully or partially denied as documentation submitted for review did not include a plan of care (POC) for all or some of the dates billed.

How to prevent this denial
•    The hospice must submit POCs for dates of service billed when responding to ADR request 
•    All dates billed must be covered by a POC to be payable under the Medicare hospice benefit
•    If more than one POC covers the dates of service in question, submit all the related plans of care for review
•    The POC must contain certain information to be considered valid. This includes:
o    Scope and frequency of services to meet the beneficiary’s/family’s needs
o    Beneficiary specific information, such as assessment of the beneficiary's needs, management of discomfort and symptom relief
o    Services that are reasonable and necessary for the palliation and management of the beneficiary’s terminal illness and related conditions

The POC must specify the hospice care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment.
All hospice care and services must follow an individualized written plan of care.
The POC must be reviewed, revised and documented as frequently as the beneficiary's condition requires, but no less frequently than every fifteen (15) calendar days.
Not Hospice Appropriate
The claim has been fully or partially denied because the documentation submitted for review did not support prognosis of six months or less.

How to prevent this denial:
•    Ensure a legible signature is present on all documentation necessary to support six-month prognosis
•    Submit documentation for review to provide clear evidence the beneficiary has a six-month or fewer prognoses which supports hospice appropriateness at the time the benefit is elected, and continues to be hospice appropriate for the dates of service billed
•    Palmetto GBA has a Local Coverage Determination (LCD) for some non-cancer diagnoses. Submit documentation which supports the coverage criteria outlined in the policy. LCDs are available under 'Medical Policies.' If documenting weight loss to demonstrate a decline in condition, include how much weight was lost over what period of time, past and current nutritional status, current weight and any related interventions.
•    Document any co-morbidity, which may further support the terminal condition of the beneficiary and the continuing appropriateness of hospice care

Physician Narrative Statement Not Present or Not Valid
The claim has been denied as the physician narrative statement is not present or not valid.

How to prevent this denial:
•    The physician must include a brief narrative explanation of the clinical findings that supports a life expectancy of six months or less as part of the certification and recertification forms, or as an addendum to the certification and recertification forms
•    If the narrative is part of the certification or recertification form, then the narrative must be located immediately prior to the physician’s signature
•    If the narrative exists as an addendum to the certification or recertification form, in addition to the physician’s signature on the certification or recertification form, the physician must also sign immediately following the narrative in the addendum
•    The narrative shall include a statement under the physician signature attesting that by signing, the physician confirms that he/she composed the narrative based on his/her review of the patient’s medical record or, if applicable his or her examination of the patient
•    The narrative must reflect the patient’s individual circumstances and cannot contain check boxes or standard language used for all patients

Auto Deny - Requested Records not Submitted
Medical records were not received in response to an Additional Documentation Request (ADR) in the required time frame; therefore, we were unable to determine medical necessity.

To prevent this denial:
•    Monitor your claim status on Direct Data Entry (DDE). If the claim is in status/location SB6001, the claim has been selected for review and records must be submitted
•    Be aware of the need to submit medical records within 30 days of the ADR date. The ADR date is in the upper left corner of the ADR request.
•    Gather all information needed for the claim and submit it all at one time
•    Submit medical records as soon as the ADR is received
•    Attach a copy of the ADR request to each individual claim
•    If responding to multiple ADRs separate each response and attach a copy of the ADR to each individual set of medical records. Ensure each set of medical records is bound securely so the submitted documentation is not detached or lost.
•    Do not mail packages C.O.D.; we cannot accept them
•    Return the medical records to the address on the ADR. Be sure to include the appropriate mail code. This ensures your responses are promptly routed to the Medical Review Department.

Face to Face Encounter Requirements Not Met
The services billed were not covered because the documentation submitted for review did not include documentation of a face to face encounter.

How to prevent this denial:
The face to face encounter must occur no more than 30 calendar days prior to the start of the third benefit period and no more than 30 calendar days prior to every subsequent benefit period thereafter.
Specific documentation related to face to face encounter requirements must be submitted for review. This includes, but is not limited to, the following:
•    The hospice physician or nurse practitioner who performs the encounter must attest in writing that he or she had a face to face encounter with the patient, including the date of the encounter
•    The attestation, its accompanying signature, and the date signed, must be a separate and distinct section of, or an addendum to, the recertification form, must be clearly titled  
•    When a nurse practitioner performs the encounter, the attestation must state that the clinical findings of that visit were provided to the certifying physician for use in determining whether the patient continues to have a life expectancy of six months or less, should the illness run its normal course

No Valid Election Statement Submitted
The services billed were not covered, as there was no valid signed notice of election (NOE) statement included with the documentation submitted for review.

How to prevent a denial:
•    A Medicare beneficiary must complete a NOE statement before the Hospice Medicare Benefit can begin. A beneficiary, who meets the eligibility requirement in the Code of Federal Regulations, 42 CFR - Part 418.20, may file a NOE statement with a particular hospice. The representative for this beneficiary may file the NOE if the beneficiary is physically or mentally incapacitated. The NOE statement must be signed no later than the first day for which the payment is claimed. It must also be signed if the beneficiary is re-electing the hospice Medicare benefit after a revocation or discharge from hospice.
•    The provider must submit a NOE statement to the intermediary for every beneficiary who elects the Hospice Medicare Benefit. A beneficiary (or his/her representative) must elect hospice care to receive it. Once the decision to receive hospice care is made, a NOE statement must be filed with a particular hospice.
•    All NOE statements must include the following information:
o    Identification of the particular hospice which will provide care
o    The beneficiary’s or representative’s acknowledgement that he or she has been given a full understanding of the palliative, rather than curative nature of hospice care, particularly the palliative rather than the curative nature of treatment
o    Acknowledgement that certain Medicare services set forth in Code of Federal Regulations, 42 CFR - paragraph (d) of section 418.24 are waived by the election
o    The effective date of the NOE statement, which may be the first day of hospice care or a later date, but may be no earlier than the date of the NOE statement
o    The signature of the beneficiary or authorized representative
•    The duration of the NOE statement will be considered to continue through the initial election period and through the subsequent election periods without a break in care as long as the beneficiary remains in the care of a hospice and does not revoke the election under the provision of Code of Federal Regulations, 42 CFR - Section 418.28
•    When a Medicare beneficiary or authorized representative elects the hospice Medicare benefit, a NOE statement must be submitted to the Medicare Administrative Contractor (MAC) prior to the submission of the first bill

Invalid Plan of Care
The claim has been fully or partially denied as the documentation submitted for review did not include a valid plan of care for all or some of the dates billed.
For a beneficiary to receive hospice care covered by Medicare, a Plan of Care (POC) must be established before services are provided. The POC is developed from the initial assessment and comprehensive assessment and services provided must be consistent with the POC.

How to prevent a denial:
•    The POC must contain certain information to be considered valid. This includes:
o    Scope and frequency of services to meet the beneficiary's/family's needs
o    Beneficiary specific information, such as assessment of the beneficiary's needs, management of discomfort and symptom relief c) Services that are reasonable and necessary for the palliation and management of the beneficiary's terminal illness and related conditions
•    The plan of care must be reviewed, revised and documented as frequently as the beneficiary's condition requires, but no less frequently than every fifteen (15) calendar days

No Certification Present
The claim has been fully or partially denied, as the documentation submitted for review did not include a certification of terminal illness to cover the dates of service billed.

No Certification for Dates Billed

The claim has been fully or partially denied as documentation submitted for review did not include a certification covering all or some of the dates billed.

Subsequent Certification Not Signed
The claim has been fully or partially denied as the documentation submitted for review did not include a certification that was signed and dated.

Initial Certification Not Timely
The claim has been fully or partially denied, as the documentation submitted for review did not include an initial certification signed timely by the medical director and attending physician.

Subsequent Certification Not Timely
The claim has been fully or partially denied, as the documentation submitted for review did not include a subsequent certification signed timely by the medical director.

No Prognosis statement
The claim has been fully or partially denied, as certification statement did not include a six month prognosis statement.

How to Prevent Denials Related to Physician Certification

•    In order to be eligible for hospice benefits under Medicare, the beneficiary must be certified as being terminally ill. The hospice must obtain written certification of terminal illness for each benefit period.
•    The hospice must include the written certification, to cover the dates of service billed, with the medical records submitted for review when responding to an ADR. All dates billed must be covered by a certification to be payable under the Medicare hospice benefit.
•    If more than one certification covers the dates of service in question, submit all the related certifications for review
•    For the first 90-day period of hospice coverage, the hospice must obtain, no later than two calendar days after hospice care is initiated, (that is, by the end of the third day), oral or written certification by the medical director or the physician member of the hospice interdisciplinary group and the beneficiary’s attending physician. If one physician is serving in both capacities, this must be clearly identified on the certification
•    Written certification must be on file in the hospice beneficiary’s record prior to submission of a claim to the MAC. If these requirements are not met, the payment begins with the day of certification.
•    The initial certification may be completed up to two weeks before hospice care is elected
•    If the attending physician and the medical director are the same, the certification must clearly identify this information
•    Certifications for subsequent benefit periods must be obtained no later than two days after the beginning of the new benefit period. Only one physician’s signature is required on a subsequent certification.
•    Verbal certification may be submitted; however, there must be documentation in the medical records to indicate the certification was obtained within the time frame indicated above
•    Verbal certification must be followed by a written certification, signed and dated by the physician prior to billing Medicare for the hospice care
•    If no verbal certification is present and the written certification is signed later than two days after the beginning of the benefit period, allowable days will begin with the date of the physician’s signature

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