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J15 HHH Postpayment Resumptive Review Status Update – 07/01/2021 - 09/30/2021

Beginning August 17, 2020, CMS directed the MACs to resume fee-for-service medical review activities beginning with postpayment reviews of items/services provided before March 1, 2020. Items and services are selected based upon high error rates and/or potential overutilization identified through data analysis.

CGS Medical Review is dedicated to the integrity of the Medicare program. CGS welcomes provider inquiries and continues to offer education sessions to ensure providers understand CMS regulations with the goal of successful reviews resulting in claim payment.

Results for service specific postpayment reviews are listed below.

5L000 Home Health Medical Necessity
Reviews Completed 610
Claims Allowed 326
Claims Denied 284
No Provider Response 66

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Top Finding: 5HC09 The initial certification was missing/incomplete/invalid; therefore, the recertification episode is denied. Refer to CMS Medicare Benefit Policy Manual (Pub. 100-02, Ch. 7, Sections 30.5.1-30.5.1.2External PDF) and CMS Medicare Program Integrity Manual (Pub. 100-08, Ch. 6, Sections 6.2-6.2.6External PDF) for information regarding Certification and Recertification Requirements and CGS Physician or Allowed Practitioner Orders, Plan of Care and Certification and Face-to-Face (FTF) Encounters for Home Health CertificationPDF Web pages and Home Health Denial Fact Sheet—Missing/Incomplete/Untimely Plan of Care or CertificationPDF Quick Resource Tool.

Resources:

5M000 Hospice LOS >730 Days
Reviews Completed 153
Claims Allowed 55
Claims Denied 98
No Provider Response 14

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Top Finding: 5PM01 According to Medicare hospice requirements, the information provided does not support terminal prognosis of six months or less. Refer to CMS Medicare Benefit Policy Manual (Pub. 100-02, Ch. 9External PDF), Hospice Local Coverage Determination (LCD), "Determining Terminal Status"External website, and CGS Hospice Denial Fact Sheet—Six-Month Terminal Prognosis Not SupportedPDF, Suggestions for Improved Documentation to Support Medicare Hospice ServicesPDF, and Appropriate Clinical Factors to Consider During Recertification of Medicare Hospice PatientsPDF Quick Resource Tools.

5M001 Hospice GIP ≥ 7 days
Reviews Completed 92
Claims Allowed 27
Claims Denied 65
No Provider Response 7

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Top Finding: 5PM02 According to Medicare hospice requirements, the documentation indicates the general inpatient level of care was not reasonable and necessary. Therefore, payment will be adjusted to the routine home care rate. Refer to CMS Medicare Benefit Policy Manual (Pub. 100-02, Ch. 9External PDF) and CGS General Inpatient Care Web page and Hospice Denial Fact Sheet/Denial Reason 5PM02: Reduced Level of Care (Medical Necessity), Denial Reason 5PX03: Reduced Level of Care (Technical)PDF Quick Resource Tool.

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Provider inquiries and education requests may be emailed to J15HHMREDUCATION@cgsadmin.com.

CGS encourages providers to request education and conduct self-monitoring based on our posted Medical Review Activity Log and by using tools such as Comparative Billing Reports (CBRs) offered through our web portal.

To learn more about the postpayment resumptive process, please refer to the following links:

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