As previously reported, the targeted probe and educate (TPE) process is replacing the medical review process used by Medicare Administrative Contractors (MAC).  Each of the three MACs – Palmetto GBA, NGS and CGS – can choose the topics for review under TPE based on existing data analysis procedures.

What topics, exactly, should hospices expect the MACs to choose and how can they best be prepared for a TPE ADR?  First, hospices should realize two things:

  1. the goal of targeted probe and educate (TPE) is to reduce/prevent improper payments, and
  2. data analysis as well as education to providers regarding their performance has encompassed that which falls outside the norm

Second, hospices should realize that CMS and MACs have published some areas within the hospice benefit which could be at risk for improper Medicare payment via the target areas on the PEPPER and previous MAC medical review topics.  Hospices should look at these areas for possible TPE topics.  PEPPER target areas this year included:

  • Live discharges not terminally ill
  • Live discharges revocation
  • Live discharges 61-179 days
  • Long length of stay (defined as >180 days)
  • Routine home care in assisted living facility
  • Routine home care in nursing facility
  • Routine home care in skilled nursing facility
  • Claims with single diagnosis coded
  • No GIP or CHC

CMS has indicated that any hospice performing at or above the 80th percentile for any PEPPER target area indicates that the hospice may be at a higher risk for improper Medicare payment. The greater the percentile value on the PEPPER, the greater consideration should be given to that target area.  Hospices should review their PEPPER results, available here, to determine if they fall into this category.  And, if the topic chosen by the hospice’s MAC is one where the hospice falls into this category or a closely related topic, the hospice should expect to receive ADRs.

Only one MAC, CGS, has published hospice TPE topics, below, and the connection to the PEPPER target areas is evident.  The two CGS TPE areas are also consistent with CGS’ past medical review work with hospices.

  • LOS with Non-Oncologic Diagnosis – This edit selects hospice providers who submitted claims with length of stay (LOS) >730 days and non-oncologic diagnosis code
  • LOS in LTC, NF or SNF – This edit selects hospice providers who submitted claims with HCPC codes Q5003 (Hospice care provided in nursing long-term care facility (LTC) or non-skilled nursing facility (NF) and Q5004 (Hospice care provided in skilled nursing facility (SNF)), for any non-oncologic diagnosis code and a length of stay greater than 180 days

Hospices should expect that the other MACs may very well choose topics that are the same as or related to the PEPPER target areas and areas the MAC has identified previously for medical review.  At a recent national conference, NGS indicated that it may choose a topic related to length of stay and general inpatient care; however, at the time this blog was published, NGS had not posted any topics.  Palmetto has not hinted at what its topics might be other than to say that it would choose topics that could be at risk for improper Medicare payment.  Areas that Palmetto has looked at in the recent past for hospices include:

  • Hospice Routine Care provided in Patient’s Home, Assisted Living Facility, LT/Non-Skilled Nursing or Skilled Nursing Facility
  • New Providers

And results of reviews for the routine home care provision, that were posted by Palmetto in October 2017, indicate the top two denial reasons as Physician Narrative Statement Not Present or Not Valid and No Valid Election Statement Submitted. Therefore, hospices should be reviewing their physician narrative statements to ensure one is present and the narrative contains sufficient information, including objective clinical findings, to support the patient’s terminal prognosis.  They should also be auditing their election statements to ensure it meets the technical requirements.  HPS Alliance members can access the Hospice Medicare Election Audit Tool as part of their membership.

In general, lack of documentation to support a patient’s terminal prognosis/eligibility for hospice care and/or the level of care billed has been a top denial reason for many MAC medical reviews, other Medicare contractor reviews, and is a concern of CMS’.  Therefore, hospices should be focusing on this documentation.  It should contain:

  • objective clinical findings that support the applicable Local Coverage Determination (LCD)*
  • evidence of a decline in the patient’s status, to indicate a terminal versus a chronic condition and for supporting the level of care billed, documentation should contain:
    • for each day of general inpatient care, the symptoms that are being managed and why they cannot be managed in any other setting
    • for each hour of continuous home care, the specific crisis that is occurring, how it impacts the patient’s condition, what the hospice is doing to resolve the issues, and why the skills of a nurse are needed for the majority of the time.

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.

Click on the MAC below to obtain its hospice LCD(s).

NGS       CGS        Palmetto