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MR Activity Log 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

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