Palmetto GBA Post Results of Hospice Probe Edits

Palmetto GBA performed a service-specific prepay probe review on Hospice claims with non-cancer diagnoses, billed with place of service Skilled Nursing Facility (HCPCS Q5004). The results for claims processed November 1, 2013 – January 31, 2014 are of 121 claims reviewed, 74 were either completely or partially denied, resulting in a claim denial rate of 61.1%. A total of $484,667.62 charges was reviewed with $171,363.21 denied, resulting in a charge denial rate of 35.3 percent. The top five reasons for denials are listed below.

1.     Plan of Care submitted does not cover the dates billed on a claim

2.     Documentation submitted does not support medical prognosis of six months or less

3.     The Face-to-Face Encounter documentation submitted was not valid

4.     The Plan of Care submitted was not valid

5.     Documentation submitted did not contain the physician narrative statement.

For more information please use the following link.

http://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Providers~Jurisdiction%2011%20Home%20Health%20and%20Hospice~Medical%20Review~Results~9G3PA23121?open&navmenu=Medical^Review||||