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J15 HHH Postpayment Resumptive Review Status Update 01/01/2021—03/31/2021

Beginning August 17, 2020, CMS directed the MACs to resume fee-for-service medical review activities beginning with postpayment reviews of items/services provided before March 1, 2020. Items and services are selected based upon high error rates and/or potential overutilization identified through data analysis.

CGS Medical Review is dedicated to the integrity of the Medicare program. CGS welcomes provider inquiries and continues to offer education sessions to ensure providers understand CMS regulations with the goal of successful reviews resulting in claim payment.

Results for service specific postpayment reviews are listed below.

5L000 Home Health Medical Necessity

Reviews Completed

667

Claims Allowed

341

Claims Denied

326

No Provider Response

109

5L000

Top Finding: 56900 Requested documentation not received/received untimely. Refer to CGS Medical Review Additional Development Request (ADR) Process Postpayment Review and myCGS MR ADR Job Aid Web pages and Postpayment Medical Review Additional Development Request (MR ADR)PDF and Success with Medical Record RequestsPDF Quick Resource Tools.

Resources:

5M000 Hospice LOS > 730 Days

Reviews Completed

152

Claims Allowed

51

Claims Denied

101

No Provider Response

8

5M000

5M000

Top Finding: 5PM01 According to Medicare hospice requirements, the information provided does not support terminal prognosis of six months or less. Refer to CMS Medicare Benefit Policy Manual (Pub. 100-02, Ch. 9External PDF), Hospice Local Coverage Determination (LCD), “Determining Terminal Status”External Website, and CGS Hospice Denial Fact Sheet—Six-Month Terminal Prognosis Not SupportedPDF, Suggestions for Improved Documentation to Support Medicare Hospice ServicesPDF, and Appropriate Clinical Factors to Consider During Recertification of Medicare Hospice PatientsPDF Quick Resource Tools.

5M001 Hospice GIP ≥ 7 days

Reviews Completed

105

Claims Allowed

19

Claims Denied

86

No Provider Response

7

5M001

5M001

Top Finding: 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. Refer to CMS Medicare Benefit Policy Manual (Pub. 100-02, Ch. 9External PDF) and CGS General Inpatient Care Web page and Hospice Denial Fact Sheet/Denial Reason 5PM02: Reduced Level of Care (Medical Necessity), Denial Reason 5PX03: Reduced Level of Care (Technical)PDF Quick Resource Tool.

Resources:

Provider inquiries and education requests may be emailed to J15HHMREDUCATION@cgsadmin.com.

CGS encourages providers to request education and conduct self-monitoring based on our posted Medical Review activity log and by using tools such as Comparative Billing Reports (CBRs) offered through our web portal.

To learn more about the postpayment resumptive process, please refer to the following links:

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