Noridian Healthcare Solutions, LLC (Noridian), as the Supplemental Medical Review Contractor (SMRC) for the CMS, is conducting post-payment review of claims for Medicare Hospice General Inpatient (GIP) Level of Care services billed on dates of service from January 1, 2020, through December 31, 2020. This notification includes the reasons for the review, documentation that will be requested in the Additional Documentation Request (ADR) letter, and resources providers may wish to consult when submitting claims.

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 is 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 will conduct 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.

Claim Sample Detail

Access related project details below.

• Documentation Requirements
• References/Resources

Documentation Requirements

Below is a list of specific documentation requirements that will be included in each Additional Documentation request (ADR) to obtain the necessary documentation to perform the review. Providers/suppliers are requested to submit each of the Documentation Requirements outlined below, if and as applicable to the claim on review.

1. Hospice Election Statement and Hospice Election Statement Addendum
   • If dates of service are on/after October 1, 2020, the election statement must include notification of the beneficiary’s right to request an election statement addendum for conditions, items, drug, or services unrelated to the terminal illness and related conditions not covered by the hospice
2. Hospice Certification of Terminal Illness (Initial and subsequent to cover billed dates of service), from Certifying Physician/Attending Physician including written and oral/verbal certification and Physician’s narrative
3. Face-to-Face Encounter and Face-to-Face Attestation statement(s) as applicable to the recertification period(s) during which the General Inpatient (GIP) level of care was provided for the dates of service under review
4. Documentation to support the medical necessity for the GIP level of care stay. This may include, but is not limited to, the following:
   • Hospice Plan of Care (POC) covering the GIP stay supporting the change in level of care including dates, reason for GIP, interventions, beneficiary’s response and collaboration between the hospice and hospital teams
   • Clinical documentation to include, but not limited to, admission history and physical, progress notes, consultation notes, nursing assessments, treatment records (including medication administration records), wound care documentation, and discharge summary.
   • Hospice team documentation to include, but not limited to, visits, assessments, and discharge planning for the DOS under review
5. Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services)
6. Advance Beneficiary Notice of Non-Coverage (ABN)/Notice of Medicare Non-Coverage (NOMNC)
7. Any other supporting documentation
8. If medical record documentation is submitted via esMD: Beneficiary identification, date of service, and provider of the service should be clearly identified on each page of the submitted documentation
9. PLEASE NOTE: It is the responsibility of the supplier or provider to obtain all documentation from the ordering/referring provider to ensure medical necessity criteria have been met

References/Resources

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.
• § 1834(m) Payment for Telehealth Services.
• § 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

• Final Rule Volume 85, No. 66. CMS-1744-IFC. Effective March 1, 2020. Retrieved from 2020-06990.pdf (govinfo.gov)

Public Law

• Robert T. Stafford Disaster Relief and Emergency Assistance Act. COMPS-2977.pdf (govinfo.gov) .

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), 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:

• Medicare Learning Network (MLN) Matters Article, MM12015 Manual Updates Related to the Hospice Election Statement and the Implementation of the Election Statement Addendum .
• Medicare Learning Network (MLN) Matters Article, SE1631 Sample Hospice Election Statement .

Last Updated Jan 11, 2023