01-099 Hospice 90 Day Stay Findings of Medical Review

Noridian Healthcare Solutions, LLC, (Noridian), as the Supplemental Medical Review Contractor (SMRC) for the CMS, has conducted post-payment review of claims for Medicare Part A hospice billed on dates of service from January 1, 2021, through December 31, 2021. Below are the review results:

Project ID Project Title Error Rate for Reviewed Claims No Response to ADR Denials
01-099 Hospice 90 Day Stay 16% 11%


Hospice is a comprehensive, holistic program of care and support for terminally ill patients and their families. Hospice care changes the focus of care from curative to comfort care for pain relief and symptom management of a beneficiary’s terminal illness.

Routine home care (RHC) is one of four levels of hospice care and is provided within the beneficiary’s home when the beneficiary is not in crisis. To be eligible for hospice, the beneficiary must be entitled to Medicare Part A, elect hospice care, and be certified as terminally ill, with a prognosis life expectancy of six months or less if the terminal illness runs its normal course.

According to the 2022 Medicare Fee-for-Service Supplemental Improper Payment Data report, the projected improper payment amount for hospice was $2.9 billion, resulting in an improper payment rate of 12.0 percent. In addition, CMS internal data has identified a potential area of vulnerability, beginning with the second benefit period, or 91st day in hospice.

Reason for Review

The SMRC was tasked to perform data analysis and conduct medical record review activities. The SMRC performed medical record review on Part A hospice claims, specifically the second benefit period, with dates of service (DOS) January 1, 2021, through December 31, 2021.

The SMRC conducted medical record reviews in accordance with applicable waivers, flexibilities, statutory, regulatory, and sub-regulatory guidance.

Common Reasons for Denial

  • Medical Documentation Not Received
    • The Medicare Program Integrity Manual (PIM) Pub. 100-08, Chapter 3, § requires providers to respond to requests for documentation within 45 calendar days of the additional documentation request for the dates of service under review. “No medical record documentation was received.” Refer to Internet-only Manual Pub 100-08, Chapter 3, §, 42 CFR 424.5(a)(6) and Social Security Act Title XVIII, § 1815(a), 1833(e), and 1862(a)(1)(A). The documentation was not submitted, or not submitted timely to support the claim as requested by the additional documentation request (ADR).
  • Invalid Election Statement
    • Section 418.24 of 42 CFR, contains requirements for a valid election statement including the hospice providing the beneficiary’s care, the beneficiary’s or representative’s (as applicable) acknowledgement of receipt of a full understanding that hospice is palliative rather than curative care, the beneficiary’s or representative’s (as applicable) acknowledgement of understanding that certain Medicare services are waived by the election, effective date of the election, the beneficiary’s designated attending physician (if any), and the document must be signed by the beneficiary or representative. The documentation submitted did not include all elements for a valid election statement.
  • Election Statement Not Received
    • Social Security Act 1861(d)(1) requires a valid election statement for admission to hospice. Also refer to 42 CFR, § 418.24 and 424.5(a)(6). “The election statement for this beneficiary was not received as requested.” Documentation submitted did not include an election statement to support the claim.


Social Security Act (SSA), Title XVII

  • §§ 1812(a)(4), (a)(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 – Requirement of Requests and Certifications
  • §§ 1815(a), (e)(2)(D) Payment to Providers of Services
  • § 1833(e) Payment of Benefits
  • § 1861(dd) Definitions of Services, Institutions, Etc. – Hospice Care
  • § 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
  • § 1893(b) Medicare Integrity Program

42 Code of Federal Regulations (CFR)

  • § 411.15(k)(1) Particular services excluded from coverage
  • § 418(A) General Provisions and Definitions
  • § 418(B) Eligibility, Election and Duration of Benefits
  • § 418.22 Certification of Terminal Illness
  • § 418.24 Election of Hospice Care
  • § 418(F) Covered Services
  • § 418 (G) Payment for Hospice Care
  • 424.5(a)(6) Conditions for Medicare Payment – Basic Conditions, Sufficient Information
  • § 424.516(f) Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare program
  • § 424.535 Revocation of enrollment in the Medicare program

Federal Register

Public Law

Internet Only Manual (IOM) Medicare General Information, Eligibility and Entitlement Manual, Publication (Pub.) 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), 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 Form CMS-R-131 Advance Beneficiary Notice of Noncoverage (ABN)

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

  • Ch. 3 Verifying Potential Errors and Taking Corrective Actions
  • Ch. 3, § Signature Requirements

Local Coverage Determination (LCD)

  • L33393 Hospice Determining Terminal Status
  • L34538 Hospice Determining Terminal Status
  • L34544 Hospice – Liver Disease
  • L34547 Hospice – Neurological Conditions
  • L34548 Hospice Cardiopulmonary Conditions
  • L34558 Hospice the Adult Failure to Thrive Syndrome
  • L34559 Hospice – Renal Care
  • L34567 Hospice Alzheimer’s Disease & Related Disorders

Local Coverage Article (LCA)

    • A52830 Billing and Coding: Hospice: Determining Terminal Status
    • A53054 Going Beyond Diagnosis: Hospice Cardiopulmonary Conditions
    • A53056 Hospice: Documenting Weight Loss for Beneficiaries with Non-Neoplastic Conditions
    • A56502 Billing and Coding: Hospice – Neurological Conditions
    • A56545 Billing and Coding: Hospice – Renal Care
    • A56610 Billing and Coding: Hospice Cardiopulmonary Conditions
    • A56639 Billing and Coding: Hospice Alzheimer’s Disease & Related Disorders
    • A56669 Billing and Coding: Hospice – Liver Disease
    • A56679 Billing and Coding: Hospice the Adult Failure to Thrive Syndrome


Last Updated Mar 19, 2024