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

End User License Agreement

These materials contain Current Dental Terminology, Fourth Edition (CDT), copyright © 2002, 2004 American Dental Association (ADA). All rights reserved. CDT is a trademark of the ADA.

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September 20, 2017

CBR Hospice Length of Stay for Non-Cancerous Diagnosis

Overview

CGS is providing a Comparative Billing Report (CBR) related to non-cancerous diagnoses and length of stay. The CBR contains data and information from 09/01/2016 to 05/31/2017.  The information contained in the report allows providers to be pre-emptive in their approach to hospice compliance and Medicare guidelines.
Non-cancerous diagnoses in combination with length of stay for beneficiaries receiving hospice services were evaluated by CGS utilizing 9 months of claims data. Claims were examined for beneficiaries utilizing the hospice benefit for length of stays greater than 240 days and greater than 730 days.
The tables below summarize the percentage of non-cancerous diagnosis groups per region for hospice LOS greater than 240 days and greater than 730 days.

Methodology

The tables below demonstrate variations in the proportion of long-stay beneficiaries (>240 days or >730 days) at the regional level. Each column is the percentage of beneficiaries with a length of stay greater than 240 days and a primary diagnosis code billed on the hospice claims. The percentage of Neoplams has been included for comparison. A period within the percentage column represents beneficiaries within that ICD-10 category but no beneficiaries exceeding a 240 day length of stay. For example, in the Midwest region there are 1.11% of beneficiaries with certain infections and parasitic diseases who have a length of stay greater than 240 days.

CGS J15 Home Health and Hospice Medicare Administrative Contractor include 15 states and the District of Columbia. These states include Colorado, Delaware, D.C., Iowa, Kansas, Maryland, Missouri, Montana, Nebraska, North Dakota, South Dakota, Pennsylvania, Utah, Virginia, West Virginia, and Wyoming.  There are additional states that also submit claims to CGS.

Table 1

Table 2

Analysis of the length of stay among hospice claims related to non-cancerous diagnosis within CGS jurisdiction is an area of concern. 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 beneficiary's appropriateness for the hospice benefit must be clearly supported in the medical record from admission and throughout the hospice care provided.

Action

CGS will initiate probe and educate reviews to address hospice length of stays greater than 240 days and greater than 730 days with non-cancer related diagnoses.

The reviews will involve identifying providers through data analysis who submit an increased number of claims for length of stay greater than 240 days and greater than 730 days with non-cancer related diagnoses. Twenty to Forty claims per provider identified as an outlier through data analysis will be randomly sampled and developed (records requested) by use of the standard automated Additional Documentation Request (ADR) process. Documentation will be reviewed for compliance with Medicare rules and regulations such as:  medical necessity; appropriate orders and signatures; administration/deliverance of the service.

Additional Documentation Request (ADR) letters will be sent individually per claim. Please submit the requested documentation within 45 days of receipt of the ADR letter. Failure to respond by the 45th day will result in denial for non-response.

What to Send

If you receive an Additional Documentation Request (ADR) from CGS, submit the requested medical record information within 45 days.  Before you send the requested records, we suggest you double-check the accuracy of your submitted claim. 

Send the following documentation when responding to the ADRs, along with other supporting documentation.  Please note: the documentation you submit in response to this request should comply with these requirements. This may require you to contact the hospital or other facility where you provided the service and obtain your signed progress notes, plan of care, discharge summary, etc.

Providers should submit the necessary documentation to support the services for the billing period being reviewed. This may include documentation that is prior to the review period, such as admission records, hospice Interdisciplinary Group (IDG) review, etc.

  • Fiss Page 7 Screenprint
  • Signed elections statement
  • Plan of care with physician certification/recertification
  • Physician Face-to-Face documentation (for third and later benefit periods)
  • Physician orders
  • IDG reviews/POC updates
  • Admission initial assessment
  • Visit notes (nursing, social worker, chaplain, etc.)
  • Physician Visit Notes
  • Other relevant documentation
  • Beneficiary’s name and date of service should be on all documentation
  • Be sure all documentation is legible and complete including signatures
  • A signature log or an attestation statement, if you question the legibility of your signature. Medicare requires that medical records entries for services provided/ordered be authenticated by the author. The signature may be hand-written or electronic; Patient identification, date of service, and provider of the service should be clearly identified on the submitted documentation. 
  • For more information regarding signature requirements for Medicare purposes, refer to the CMS Medicare Program Integrity Manual (Pub. 100-08), chapter 3, section 3.3.2.4 and CMS MLN Matters article MM6698, “Signature Requirements for Medical Review Purposes.”

Options for Submitting Records

Submit your documentation so that it is received by CGS on/before 45 days ("DUE DATE" on FISS Page 07). Ensure that you allow ample time for mailing, and processing of the documentation when received.  This will prevent the claim from inadvertently denying.

  • Mail to the address that appears on FISS Page 07:

    CGS J15 MAC
    J15 – HHH Correspondence
    PO Box 20014
    Nashville, TN 37202

  • Submit using the Electronic Submission of Medical Documentation (esMD)
  • MyCGS Portal is a free web portal that allows you to submit your ADR documentation directly to CGS, and will help to ensure a timely response to an MR ADR.  For more information on submitting MR ADR documentation via myCGS, refer to the myCGS User Manual, Chapter 7: 'Forms' Tab.  myCGS also provides a secure message confirming receipt of the documentation, and a second message confirming it was accepted.
  • CGS will also accept documentation submitted via Fax 1.615.660.5981.

Notification of Results

For each ADR response received within the 45 day time frame, our goal is to document and process the individual review determination within 30 calendar days.

Providers with significant denials will be contacted for one-on-one education.

Additional Resources and Information

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