Home Health and Hospice Medical Review Activity Log
Hospice Targeted Probe and Educate
The primary focus of these reviews is to determine whether the medical record documentation supports the medical necessity of the services billed per Medicare guidelines.
Review Topic | Edit Numbers | Description | Review Type | Status |
---|---|---|---|---|
LOS with Non-Oncologic Diagnosis | 5D000 5E000 5F000 |
This edit selects hospice providers who submitted claims with length of stay (LOS) >730 days and non-oncologic diagnosis code | Targeted Probe and Educate Prepayment Review | Active |
GIP LOC | 5D006 5E006 5F006 |
This edit selects hospice providers who submitted claims with revenue code 0656 greater than or equal to 7 days | Targeted Probe and Educate Prepayment Review | Active |
New Providers | 5D008 5E008 5F008 |
This edit selects hospice claims for relatively new providers who have submitted at least 50 claims. | Targeted Probe and Educate Prepayment Review | Active |
LOS 313-515 days | 5D010 5E010 5F010 |
This edit selects hospice providers who submitted claims with a length of stay (LOS) 313-515 days. | Targeted Probe and Educate Prepayment Review | Active |
Home Health Targeted Probe and Educate
The primary focus of these reviews is to determine whether the medical record documentation supports the medical necessity of the services billed per Medicare guidelines.
Review Topic | Edit Numbers | Description | Review Type | Status |
---|---|---|---|---|
Home Health Medical Necessity | 5A007 5B007 5C007 |
This edit selects providers who submitted home health claims with 2 to 6 visits and diagnosis code I11.0, Z46.6, J44.0, J44.1, J44.81, J44.89, J44.9, (J44, J44.8 discontinued 10.01.2023), I10, G20.A1, G20.A2, G20.B1, G20.B2, G20.C, (G20 discontinued 10.01.2023), I25.10, N39.0, J18.9, or I87.2. | Targeted Probe and Educate Prepayment Review | Active |
New Providers | 5A006 5B006 5C006 |
This edit selects home health claims for relatively new providers who have submitted at least 50 claims. | Targeted Probe and Educate Prepayment Review | Active |
Home Health Medical Necessity | 5N000 5T000 5V000 |
This edit selects providers who submitted home health claims with 2 to 6 visits and diagnosis code I11.0, Z46.6, J44.0, J44.1, J44.81, J44.89, J44.9, (J44, J44.8 discontinued 10.01.2023), I10, G20.A1, G20.A2, G20.B1, G20.B2, G20.C, (G20 discontinued 10.01.2023), I25.10, N39.0, J18.9, or I87.2. | Targeted Probe and Educate Round 1 Postpayment Round 2 Prepayment Round 3 Prepayment |
Active |
Updated: 03.18.24