Noridian Healthcare Solutions, LLC (Noridian), as the current Supplemental Medical Review Contractor (SMRC) for the Centers for Medicare and Medicaid Services (CMS), is conducting post-payment review of claims for Medicare Part A hospice, billed on dates of service from January 1, 2021, through December 31, 2021. This notification includes the reasons for the review, documentation that will be requested in the Additional Documentation Request (ADR) letter, and resources providers/suppliers may wish to consult when submitting claims.

Background

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 ran its normal course.

According to the 2022 Comprehensive Error Rate Testing (CERT) report, the projected improper payment amount for hospice was $2.9 billion, resulting in an improper payment rate of 12.0 percent. Additionally, 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 will perform 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 will conduct medical record reviews in accordance with applicable waivers/flexibilities/statutory, regulatory, and sub-regulatory guidance.

Claim Sample Detail

Access related project details below.

• Documentation Requirements
• References

Documentation Requirements

Below is a list of specific documentation requirements that will be included in each 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 and Attending Physician (if applicable) including written and oral/verbal certification (if applicable) and Physician’s narrative
3. Medication Administration Record (MAR) and/or Infusion Flowsheet documenting the quantity administered include a dose, route, and frequency given
4. Physician Order for Hospice
5. Hospice initial and comprehensive assessment, and updated assessments covering all specified dates of service
6. Interdisciplinary Team/Group (IDG/IDT) meeting notes with full list of participants and clear distinction of professional disciplines
7. Documentation that supports the beneficiary’s need for the level and frequency of home health or hospice services provided, including any changes during the period under review
8. Advance Beneficiary Notice of Non-Coverage (ABN)/ Notice of Medicare Non-Coverage (NOMNC)
9. Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services)
10. Any other supporting documentation
11. 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
12. 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

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(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

• 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), 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, § 3.3.2.4 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

Other

• CMS (2020) Hospice: CMS Flexibilities to Fight COVID-19. Hospice CMS Flexibilities Document
• 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 .
• U.S. Department of Health and Human Services (2020) Public Health Emergency: Determination that a Public Health Emergency Exists.
  https://www.phe.gov/emergency/news/healthactions/phe/Pages/2019-nCoV.aspx

Last Updated Jun 30, 2023