Home Health and Hospice Medical Review Activity Log
Hospice Postpayment
Review Topic |
Reason Code |
Description |
Review Type |
Status |
---|---|---|---|---|
LOS 730+ days |
5M000 |
This review selects any hospice claim with a length of stay (LOS) 730+ days excluding diagnosis codes between C00 and D49.9 submitted with dates of service prior to March 1, 2020. |
Postpayment |
Active |
GIP ≥ 7 days |
5M001 |
This review selects any hospice claim with revenue code 0656 greater than or equal to 7 days submitted with dates of service prior to March 1, 2020. |
Postpayment |
Active |
Hospice Targeted Probe and Educate
Review Topic |
Edit Numbers |
Description |
Review Type |
Status |
---|---|---|---|---|
LOS with Non-Oncologic Diagnosis |
5D000 |
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 |
Paused |
LOS in LTC, NF or SNF |
5D004 |
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 with a length of stay greater than 180 days |
Targeted Probe and Educate Prepayment Review |
Paused |
GIP LOC |
5D006 |
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 |
Paused |
LOS >180 Days |
5D002 |
This edit selects hospice providers with LOS greater than 180 days |
Targeted Probe and Educate Prepayment Review |
Paused |
LOS > 120 Days |
5D003 |
This edit selects hospice providers with LOS greater than 120 days |
Targeted Probe and Educate Prepayment Review |
Paused |
New Providers |
5D008 |
This edit selects hospice claims for relatively new providers who have submitted at least 50 claims. |
Targeted Probe and Educate Prepayment Review |
Paused |
Home Health Postpayment
Review Topic |
Reason Code |
Description |
Review Type |
Status |
---|---|---|---|---|
Home Health Medical Necessity |
5L000 | This review selects any home health claim with 2 to 6 visits and a diagnosis code of I11.0, Z46.6, J44.1, I10, J44.9, G20, I25.10, N39.0, J18.9, or I87.2 submitted with dates of service prior to March 1, 2020. | Postpayment | Active |
Home Health Targeted Probe and Educate
Review Topic |
Edit Numbers |
Description |
Review Type |
Status |
---|---|---|---|---|
Home Health Eligibility and Medical Necessity |
5A000 |
This edit selects providers who submitted home health claims with errors as identified in HH probe and educate round 2 |
Targeted Probe and Educate Prepayment Review |
Paused |
LOS with Hypertension |
5A001 |
This edit selects home health claims for providers who submitted diagnosis Hypertension and a length of stay greater than 120 days |
Targeted Probe and Educate Prepayment Review |
Paused |
No response to ADR |
5A004 |
This edit selects providers who fail to respond to ADRs (additional development requests) |
Targeted Probe and Educate Prepayment Review |
Paused |
Low Visit Utilization |
5A005 |
This edit selects home health claims for providers who submit only 5 visits in an 60 day episode |
Targeted Probe and Educate Prepayment Review |
Paused |
LOS >120 Days |
5A002 |
This edit selects home health claims for providers who submit claims with a LOS greater than 120 days |
Targeted Probe and Educate Prepayment Review |
Paused |
LOS >180 Days |
5A003 |
This edit selects home health claims for providers who submit claims with a LOS greater than 180 days |
Targeted Probe and Educate Prepayment Review |
Paused |
New Providers |
5A006 |
This edit selects home health claims for relatively new providers who have submitted at least 50 claims. |
Targeted Probe and Educate Prepayment Review |
Paused |
Updated: 10.01.20