Targeted Probe and Educate (TPE) is continuing to be a problem for Hospice providers with some advancing to rounds 2 and 3 of the audit.
This demonstration, which includes hospices receiving 20-40 claim requests for Additional Development Requests (ADR) in each round, have hospices wondering if they are going to be targeted next.
Hospices failing to show improvement after round 3 will be referred to CMS for next steps which may include 100 % prepay review, extrapolation and/or a referral to a recovery auditor placing the agency’s viability at risk.
HPS is experiencing many ADR denials for both technical issues and documentation not supporting the terminal prognosis, which results in agencies being unable to stay under the MAC (Medicare Administrative Contractor) error percentages.
Avoid Additional Rounds of TPE
In order to avoid advancing to the next round of TPE, the hospice’s calculated error percentage at the end of each round must be less than the percentage set by the MAC below:
- CGS: 25% or less
- NGS: 15% or less
- Palmetto GBA: 20% or less
Overall, the Top ADR denial reason continues to be for lack of documentation to support the required six months or less prognosis.
Additional claim denials include:
- Issues surrounding the hospice election statement
- The Certification of Terminal Illness
- Face-to-Face requirements (when applicable)
CGS reports, “69% (improved from 73%) of claims reviewed from October 1, 2017-September 30, 2019 were denied because the submitted documentation did not support a terminal prognosis of 6 months or less with Face-to-Face (F2F) denials for claims falling in the third benefit period and beyond accounting for 7% of denials and invalid hospice plan of care for approximately 6% of the total TPE denials.”
NGS reports, “Issues with documentation not supporting terminal prognosis continues to be the reason why providers will be moving onto round two and three of TPE. Other denial reasons include invalid, missing or untimely hospice verbal/written certifications and physicians certification statement not present or invalid.”
Palmetto GBA reports, “Denials for invalid/missing Hospice election Statement, invalid certifications including missing physician narrative, missing plan of care and IDG documentation for the dates of services billed and documentation does not support the level of care billed including GIP services not reasonable and necessary.”
What does this mean?
- The reviewer is not finding enough documentation regarding the patient’s current condition to support a prognosis of six months or less. It is imperative the documentation submitted shows the patient’s terminal status, for the claim dates being reviewed, to avoid denials.
- Technical requirements are not being met within the Medicare Hospice Benefit Election form and the Certification of Terminal Illness (CTI) required for payment.
Avoid Denials For Hospice Eligibility
Avoid denials for hospice eligibility by focusing on documentation to support disease progression of the terminal illness and related conditions including the following:
- Support for both non-reversible and persistent symptoms of disease progression
- Any change in the patient’s condition from baseline that supports ongoing disease progression
- Objective clinical findings to support the applicable Local Coverage Determination (LCD)*
- Patient specific assessment findings for symptoms of disease progression such as weight loss, decrease in appetite and sleeping patterns must be quantified and include changes over time when used to support prognosis.
Common ADR Technical Denials
- Certification of Terminal Illness (CTI) missing or untimely.
- Initial 90-day CTI was not completed by both the hospice and patient named attending physician, when applicable.
- The physician’s signature attesting to composing the CTI narrative is not located directly below the CTI narrative as required. According to the Medicare Benefit Policy Manual, Chapter 9 for hospice, Section 20.1:
- “The narrative shall include a statement directly above the physician’s signature attesting that by signing, the physician confirms that he/she composed the narrative based on his/her review of the patient’s medical record or, if applicable, his or her examination of the patient. The physician may dictate the narrative.”
- “If the narrative is part of the certification or recertification form, then the narrative must be located immediately above the physician’s signature.”
- Verbal Certification not obtained within 2 calendar days, after the first day of the benefit period when written certification is not obtained.
- The Face-to-Face (F2F) requirement not met for claim dates that fall within the third benefit period and beyond.
- Missing the actual F2F encounter visit note.
- Certification is missing the F2F attestation when performed by a Nurse Practitioner (NP) as either a part of or an addendum to, the Certification of Terminal Illness (CTI).
- The F2F encounter was not completed timely within 30 days of the first day of the new benefit period.
Preparing The ADR Response
- Consider including documentation prior to and following the claim dates being reviewed that support the terminal prognosis.
- Be sure to include the certification documentation for the initial benefit period and if the dates under review include 2 benefit periods, you must send the certification documentation for both.
- A clinical review of the documentation should be completed prior to submitting the ADR response.
Our Targeted Probe and Educate consulting team would be happy to assist with reviewing charts that have been selected for ADR reviews or answer any additional questions you may have. We are currently assisting agencies across the country through TPE.
*LCDs are specific to each MAC and provide Medicare hospice coverage guidance for providers.