Each quarter, the CGS Medical
Review Department evaluates all current edits to ensure they continue to be
effective in selecting the most vulnerable claims, and that resources are used
effectively. In evaluating all our widespread edits, we identified edit 5048T,
which selects hospice claims with a length of stay of 999 days or more, has
shown a significant decrease in error rates. However, analysis of the length of
stay among hospice claims for certain states within CGS jurisdiction is still
an issue. Additionally, a 2013 report from the Center for Medicare and Medicaid
Services (CMS) titled "Medicare Spending Variation: Our Shared
Challenge" indicated several states had a higher hospice spending per
beneficiary derived from 2012 data. In an effort to identify claims before they
become an issue due to length of stay, CGS will be implementing a new
widespread edit that will select claims with a length of stay between 150 days
and 365 days for providers that bill to CGS within the states of NH, ID, GA,
UT, CO, DE, MO, AL, AR, KS, TS, and WV. Widespread edit 5048T will be
discontinued once this new edit 5118T is implemented.
In addition, widespread edit
5091T selects claims when the beneficiary resides in a nursing home, the
hospice length of stay is greater than 180 days, and the principal diagnosis is
debility, unspecified. Last quarter, this edit had the highest denial rate of
all four widespread hospice edits at 61%. The top denial reason for this edit
continues to be 5PTER, six-month terminal prognosis not supported.
Due to this edit's on-going
error rate and based on clarifications made by the CMS in the Fiscal Year 2014
Hospice Final Rule in regards to principal diagnosis coding, the parameters for
edit 5091T will be expanded to include any non-oncologic diagnosis code.
Medical records should contain
enough clinical factors and descriptive notes to show the illness is terminal
and progressing in a manner that a physician would reasonably have concluded
that the beneficiary's life expectancy is six months or less. The top denial
reason, 5PTER, is related to the common obstacle of documenting a six-month
terminal prognosis. The CMS Medicare
Benefit Policy Manual (CMS
Pub. 100-02), Ch. 9, states an individual is eligible for the Medicare hospice
benefit when that individual has a terminal illness with a life expectancy of
six months or less if the terminal illness runs its normal course.
Documentation is essential for patients that have remained on the hospice
benefit for an extended length of time, or for patients that have chronic
illnesses or general decline. These diagnoses alone may not support a six-month
or less life expectancy; therefore, documentation is depended upon to show why
the patient is hospice appropriate. The patient's appropriateness for the hospice
benefit must be clearly supported in the medical record from admission and
throughout the hospice care provided. To assist providers in improving their
documentation, a quick resource tool, "Suggestions for Improved
Documentation to Support Medicare Hospice Services"
is available on the CGS website.
Suggestion for Improved Documentation to
Support Medicare Hospice Services Link:
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