License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

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Hospice Denial Reason Codes

Below is a listing of the hospice denial reason codes. Providers can access denial reason code definitions by accessing the denied claim using the Fiscal Intermediary Standard System (FISS) Claim Inquiry menu (Option 12), and pressing F1 to view the reason code narrative. Visit the "Hospice Top Medical Review Denial Reason Codes" Web page for quarterly hospice medical review denial data.

Denial Code	Description
5PX06	The notice of election is invalid because it doesn't meet statutory/regulatory requirements. The notice of election is invalid because it does not meet statutory/regulatory requirements including identification of the hospice providing care to the beneficiary. The notice of election is invalid because it does not meet statutory/regulatory requirements including notifying the beneficiary that care is palliative versus curative. The notice of election is invalid because it does not meet statutory/regulatory requirements including notifying the beneficiary certain Medicare services are waived by this election. The notice of election is invalid because it does not meet statutory/regulatory requirements including the date of the election. The notice of election is invalid because it does not meet statutory/regulatory requirements including the beneficiary or representatives signature. The notice of election is invalid because it does not meet statutory/regulatory requirements including that the designated attending physician is listed on the election. The notice of election is invalid because it does not meet statutory/regulatory requirements including that the designated attending physician was the beneficiary/representatives choice. Reference— Please refer to CMS Publication 100-02, Chapter 9, Section 20.2.1 for information regarding Hospice Election.
5PX07	The notice of election for this beneficiary was not received as requested. Reference— Please refer to CMS Publication 100-02, Chapter 9, Section 20.2.1.1 for information regarding Hospice Notice of Election.
5PC02	No certification present in the documentation submitted for the dates billed. No certification present in the documentation submitted for the dates billed. No initial certification present in the documentation submitted of the dates billed. Reference— Please refer to CMS Publication 100-02, Chapter 9, Section 20.1 for information regarding Timing and Content of Certification.
5PC04	Subsequent certification not signed by physician. Reference— Please refer to CMS Publication 100-02, Chapter 9, Section 20.1 for information regarding Timing and Content of Certification.
5PC06	Subsequent certification not signed timely by physician. Reference— Please refer to CMS Publication 100-02, Chapter 9, Section 20.1 for information regarding Timing and Content of Certification
5PC07	Certification does not include the 6-month terminal prognosis statement. Subsequent certification does not include the 6-month terminal prognosis statement. Certification does not include the 6-month terminal prognosis statement. Reference— Please refer to CMS Publication 100-02, Chapter 9, Section 20.1 for information regarding Timing and Content of Certification
5PC01	The physician narrative statement was not present or was not valid. The physician narrative statement was not present. The physician narrative statement was not valid since it does not support a life expectancy of six months or less or was signed before the face-to-face encounter. The physician narrative statement was not valid since it does not include a valid attestation statement. Reference— Please refer to CMS Publication 100-02, Chapter 9, Section 20.1 for information regarding Timing and Content of Certification
5PC03	Initial certification not signed by physician(s). Initial Certification not signed by designated attending and/or certifying physicians. Reference— Please refer to CMS Publication 100-02, Chapter 9, Section 20.1 for information regarding Timing and Content of Certification
5PC05	Initial certification not signed timely by physician(s). Initial Certification not signed by designated attending and/or certifying physicians timely. Reference— Please refer to CMS Publication 100-02, Chapter 9, Section 20.1 for information regarding Timing and Content of Certification
5PC10	According to Medicare Hospice requirements, the hospice must obtain, no later than 2 calendar days after hospice care is initiated, oral or written certification of the terminal illness by the medical director of the hospice and the individual's attending physician if so designated. There is no verbal order and the physician signature date is after the billing period reviewed. Reference— Please refer to CMS Publication 100-02, Chapter 9, Section 20.1 for information regarding Timing and Content of Certification
5PC08	Face-to-Face Encounter requirements not met. Face-to-Face encounter requirements not met as encounter did not occur within required timeframes. Face-to-Face encounter requirements not met as there was no valid attestation statement. Reference— Please refer to CMS Publication 100-02, Chapter 9, Section 20.1 for information regarding Timing and Content of Certification
5PC09	The hospice plan of care does not meet the requirements set forth in the code of federal regulations. The hospice plan of care does not meet requirements set forth in the code of federal regulations and/or none was submitted. Reference— Please refer to CMS Publication 100-02, Chapter 9, Section 40 for information regarding Benefit Coverage
5PM01	According to Medicare hospice requirements, the information provided does not support a terminal prognosis of six months or less. Reference— Please refer to CMS Publication 100-02, Chapter 9, Section 10 for information regarding Requirements – General and LCD L34538.
5PX01	Some of the continuous care hours billed were not documented in the submitted medical record. Reference— Please refer to CMS Publication 100-02, Chapter 9, Section 40.2.1 for information regarding Continuous Home Care (CHC)
5PM05	According to Medicare hospice requirements, the documentation indicates that the continuous home care was not reasonable and necessary. Therefore, payment will be adjusted to the routine home care rate. Documentation submitted for continuous care did not support a minimum of 8-hours of care during a 24-hour day. Therefore payment will be adjusted to the routine home care rate for those dates. Documentation submitted for continuous care did not support the care was predominately nursing care. Therefore payment will be adjusted to the routine home care rate for those dates. Documentation shows continuous care provided after patient expired. Therefore the units billed after the patient died will be denied adjusted to the routine home care rate for those dates. Reference— Please refer to CMS Publication 100-02, Chapter 9, Section 40.2.1 for information regarding Continuous Home Care (CHC)
5PM04	According to Medicare hospice requirements, the documentation does not support that the requirements for respite care were met. Therefore, payment will be adjusted to the routine home care rate. Reference— Please refer to CMS Publication 100-02, Chapter 9, Section 40.1.5 and 40.2.2 for information regarding Short-Term Inpatient Care and Respite Care
5PX03	According to Medicare hospice requirements, the documentation indicates the inpatient respite care exceeded five days. Respite days greater than 5 are paid at the routine home care rate. Reference— Please refer to CMS Publication 100-02, Chapter 9, Section 40.1.5 and 40.2.2 for information regarding Short-Term Inpatient Care
5PM02	According to Medicare hospice requirements, the documentation indicates the general inpatient level of care was not reasonable and necessary. Therefore, payment will be adjusted to the routine home care rate. Reference— Please refer to CMS Publication 100-02, Chapter 9, Section 40.1.5 for information regarding Short-Term Inpatient Care
5PM03	According to Medicare hospice requirements, the documentation indicates the level of care was at the respite level of care not at the general inpatient level of care. Therefore, payment will be adjusted to the respite care rate. According to Medicare hospice requirements; the documentation indicates the general inpatient level of care was not reasonable and necessary. Therefore payment will be adjusted to the respite level of care rate. Reference— Please refer to CMS Publication 100-02, Chapter 9, Section 40.1.5 and 40.2.2 for information regarding Short-Term Inpatient Care and Respite Care
5PM07	According to Medicare Hospice requirements, the physician services were not reasonable and necessary or were administrative in nature including review, supervision and update of the care and services noted in the hospice care plan. Documentation to support physician services was not submitted as requested. According to Medicare hospice requirements; the documentation does not support the physician services were reasonable and necessary. Reference— Please refer to CMS Publication 100-02, Chapter 9, Section 40.1.3 for information regarding Physician Services
5PD01	According to Medicare hospice requirements; physician services performed by a nurse practitioner should be billed with a GV modifier. Reference— Please refer to CMS Publication 100-04, Chapter 11, Section 40.2 for information regarding Processing Professional Claims for Hospice Benefit and CMS Publication 100-2, Chapter 9, Section 40.1.3.2 Nurse Practitioners as Attending Physicians

Updated: 03.23.20

License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

AMA Disclaimer of Warranties and Liabilities.

CMS Disclaimer

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

Hospice Denial Reason Codes

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