01-084 Hospice General Inpatient (GIP) Level of Care Findings of Medical Review

Noridian Healthcare Solutions, LLC (Noridian), as the Supplemental Medical Review Contractor (SMRC) for CMS, has conducted post-payment review of claims for Medicare Hospice general inpatient (GIP) level of care billed on dates of service from January 1, 2020, through December 31, 2020. Below are the review results:

Project ID Project Title Error Rate for
Reviewed Claims		 No Response
to ADR Denials
01-084 Hospice General Inpatient (GIP) Level of Care 78% 5%

Background

The Office of Inspector General (OIG) of the U.S. Department of Health and Human Services published a portfolio report (OEI-02-16-00570) in July 2018 titled, “Vulnerabilities in the Medicare Hospice Program Affect Quality Care and Program Integrity,” which identified that Medicare paid hundreds of millions of dollars to hospices that billed inappropriately for higher levels of care when the beneficiary did not need it. Reviews were conducted of individual hospices and found improper payments ranging from $447,000 to $1.2 million for services not meeting Medicare requirements.

According to the Comprehensive Error Rate Testing (CERT) report, the projected improper payment amount for hospice during the 2021 report period was $1.7 billion, resulting in an improper payment rate of 7.8% for hospice services.

GIP care is one of the four levels of hospice care provided for pain control and symptom management. To be considered GIP, the care must be provided in an inpatient facility and cannot be managed in other outpatient settings. GIP level of care is intended to be short-term and may only be provided in a Medicare-certified hospice unit, hospital, or a skilled nursing facility (SNF).

Reason for Review

The SMRC was tasked with performing claim review on a sample of hospice GIP claims with dates of service from January 1, 2020, through December 31, 2020. The SMRC conducted medical record reviews in accordance with applicable statutory, regulatory, and sub-regulatory guidance and in keeping with the waivers and flexibilities in place during the Public Health Emergency (PHE) time period.

Common Reasons for Denial

  • Medical Necessity
    • Internet-Only Manual (IOM) 100-02, Medicare Benefit Policy Manual (MBPM) Chapter 9, Section 40; and IOM 100-04, Medicare Claims Processing Manual (MCPM) Chapter 11. According to Medicare hospice requirements, the documentation indicates the general inpatient (GIP) level of care was not reasonable and necessary. Therefore, payment will be adjusted to the routine home care (RHC) rate. GIP care is allowed when the patient’s medical condition warrants a short-term inpatient stay for pain control or acute or chronic symptom management that cannot feasibly be provided in other settings. The medical record documentation did not support the beneficiary required GIP services to manage symptoms such as pain, intractable nausea and/or vomiting, or shortness of breath not responding to current treatments, and/or when the beneficiary required an increased level of monitoring by clinicians; and these services could not feasible be provided in any other setting.
  • Insufficient Documentation
    • Social Security Act (SSA) XVIII, Section 1861(dd) and SSA 1862(a)(1)(A); 42 Code of Federal Regulations (CFR) 418.302; Internet Only Manual (IOM), Medicare Benefit Policy Manual (MBPM) 100-02 Chapter 9, Section 40.1.5; IOM, Medicare Program Integrity Manual (MPIM) 100-08, Chapter 3, Sections 3.4.1.3, 3.6.2.1, and 3.6.2.2. Insufficient documentation was submitted to support the intensity of care was directed towards pain control or symptom management that could not have been managed in any other setting. GIP level of care is allowed when the patient’s medical condition warrants a short-term inpatient stay for pain control, and/or acute or chronic symptom management that cannot feasibly be provided in other settings. No inpatient facility documentation was received to support the GIP services billed, and insufficient medical record documentation was submitted to support correct coding the claim to the routine home care level of care.
  • No Inpatient Facility Documentation
    • Internet-Only Manual (IOM) 100-02, Medicare Benefit Policy Manual (MBPM) Chapter 9, Section 20, Social Security Act (SSA) 1814(a)(7), and 42 Code of Federal Regulations (CFR) 418.20 and 418.22. No medical record documentation was received. GIP care is allowed when the patient’s medical condition warrants a short-term inpatient stay for pain control or acute or chronic symptom management that cannot feasibly be provided in other settings. No inpatient facility documentation was received to support the GIP services billed, but sufficient medical record documentation was submitted to support correct coding the claim to routine home care services.

References

Social Security Act (SSA), Title XVIII

  • § 1812(a) (4-5) & (d)(1) Scope of Benefits
  • § 1814(a)(2) Physician Certification of Medical Necessity
  • § 1814(a)(7) Conditions of and Limitations on Payment for Services
  • § 1815(a) Providers Must Furnish Information
  • § 1815 (e)(2)(D) Payment to Providers of Services
  • § 1833(e) Payment of Benefits
  • § 1861(dd) Hospice Care; Hospice Program
  • § 1862(a)(1)(c) Exclusions from Coverage and Medicare as Secondary Payer
  • § 1879(a)(1) & (g)(2) Limitation on Liability of Beneficiary where Medicare Claims are Disallowed

Title 42 of the Code of Federal Regulations (CFR)

  • § 418(A) General Provisions and Definitions
  • § 418(B) Eligibility, Election and Duration of Benefits
  • § 418(F) Covered Services
  • § 418(G) Payment for Hospice Care
  • § 424.5(a)(6) Basic Conditions

Federal Register

Public Law

Internet Only Manual (IOM), Medicare General Information, Eligibility and Entitlement Manual, Publication 100-01

  • Chapter (Ch.) 4, § 60 Certification and Recertification by Physicians for Hospice Care
  • Ch. 5, § 60 Hospice Defined

IOM, Medicare Benefit Policy Manual (MBPM), Publication (Pub.) 100-02

  • Ch. 9, § 10 Requirements-General
  • Ch. 9, § 20 Certification and Election Requirements
  • Ch. 9, § 40 Benefit Coverage

IOM, Medicare Claims Processing Manual (MCPM), Pub. 100-04

  • Ch. 11 Processing Hospice Claims
  • Ch. 30, § 50 Advance Beneficiary Notice of Non-coverage (ABN)

IOM, Medicare Program Integrity Manual (MPIM), Pub. 100-08

  • Ch. 3 Verifying Potential Errors and Taking Corrective Actions

Local Coverage Determination (LCD)

  • L33393 Hospice Determining Terminal Status. Effective October 1, 2015
  • L34538 Hospice Determining Terminal Status. Effective October 1, 2015
  • L34544 Hospice Liver Disease. Effective October 1, 2015
  • L34547 Hospice Neurological Conditions. Effective October 1, 2015
  • L34548 Hospice Cardiopulmonary Conditions. Effective October 1, 2015
  • L34558 Hospice: The Adult Failure to Thrive Syndrome. Effective October 1, 2015
  • L34559 Hospice Renal Care. Effective October 1, 2015
  • L34566 Hospice HIV Disease. Effective October 1, 2015
  • L34567 Hospice Alzheimer’s Disease & Related Disorders. Effective October 1, 2015

Local Coverage Article (LCA)

  • A52830 Billing and Coding: Hospice: Determining Terminal Status. Effective October 1, 2015
  • A53054 Going Beyond Diagnosis: Hospice Cardiopulmonary Conditions. Effective October 1, 2015
  • A53056 Hospice: Documenting Weight Loss for Beneficiaries with Non-Neoplastic Conditions. Effective October 1, 2015
  • A56502 Billing and Coding: Hospice – Neurological Conditions. Effective April 18, 2019
  • A56545 Billing and Coding: Hospice – Renal Care. Effective May 9, 2019
  • A56610 Billing and Coding: Hospice Cardiopulmonary Conditions. Effective June 6, 2019
  • A56639 Billing and Coding: Hospice Alzheimer’s Disease & Related Disorders. Effective July 4, 2019
  • A56669 Billing and Coding: Hospice-Liver Disease. Effective July 11, 2019
  • A56677 Billing and Coding: Hospice-HIV Disease. Effective July 4, 2019
  • A56679 Billing and Coding: Hospice: The Adult Failure to Thrive Syndrome. Effective July 4, 2019

Other:

Last Updated Nov 13, 2023