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National Government Services Announces Two Hospice Medicare Review Focus Areas


National Government Services (NGS) has initiated two widespread service-specific probes to ensure that medical records support that the documentation and criteria requirements are met for the hospice services, and that the hospice services are medically reasonable and necessary. NGS is the Medicare Administrative Contractor (MAC) for Jurisdiction K for home health and hospice, which includes the states of CT, MA, ME, NH, RI and VT. Both probes started in July 2017 (refer to MPP Edit # 5A121 and MPP Edit # 5A124).

The first probe focuses on hospice services provided under general inpatient level of care.  The second probe focuses on hospice services provided to beneficiaries with non-cancer diagnosis(es) and a length of stay (LOS) greater than 180 days.

Providers should ensure the medical records for their patients contain supporting documentation and criteria requirements that meet the hospice services Medicare regulations, and that the hospice services being provided are medically necessary and reasonable.

The MAC will require the following medical records/documentation for the previous 30 days from the claim’s billed dates of service:

  • Hospice election form
  • Hospice certification/recertification
  • Hospice initial admission assessment documentation
  • Hospice plan of care
  • Documentation for all services provided (can include but is not limited to: nursing, therapy, social services, volunteer support)
  • Interdisciplinary team documentation
  • Documentation that supports medical necessity for general inpatient hospice care billed
  • Revocation of hospice election, if appropriate
  • Documentation of any change in hospice status
  • Hospice discharge documentation, if appropriate

Simione Healthcare Consultants advises providers to include the last Interdisciplinary Group (IDG) meeting/update to the Plan of Care (POC) documents from the previous month, along with the month being requested.  Additionally, for episodes that started on or after 1/1/2011, the documentation must include the face to face encounter with the signature of the certifying physician per “Centers for Medicare & Medicaid Services Internet Only Manual Publication 100-02, Medicare Benefit Policy Manual, Chapter 9, Section 20.1, Timing and Content of Certification”.  Refer to: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c09.pdf

Hospice billing staff should monitor for these pending document requests. Providers must respond promptly to requests from the MAC, as the claim will be denied for untimely filing if not submitted by the deadline. Providers can submit additional data request (ADR) documentation electronically through the NGC Connex portal or by fax/mail. For more information on ADR submission, please visit www.ngsmedicare.com.

How Simione Can Help

The time is now for providers to ensure that all clinical and regulatory documentation is compliant with Medicare regulations, and that the hospice’s clinical record review and Medicare appeals processes are effective and efficient.  Simione can provide assistance with all aspects of these Medicare audits, including, but not limited to clinical record reviews, ADR processing, appeals, and staff education to improve clinical documentation.  For information and assistance on improving your clinical documentation, call 844.215.8822 or email.