CGS Initiates Widespread Review of Hospice Providers

Some Hospice Claims to be Reviewed for Medical Necessity.

CGS recently announced that as a result of analysis of errors related to claims selected for medical review between October 20, 2011, through March 31, 2012,  they will initiate a continuing widespread review for hospice providers.

The focus of the new edit (5101T) will be hospice claims for:

  • Debility
  • Alzheimer’s disease
  • and Chronic Airway Obstructions 

Once selected, claims will be reviewed for medical necessity (e.g. compliance with CMS guidelines, contractor local coverage determinations (LCDs), correct billing and coding).  CGS indicated that on the prior review, the majority of denials received by providers were related to the six-month terminal prognosis not being supported in the medical record documentation and for missing, incomplete or untimely certifications. It is critical that providers frequently review their documentation procedures and make sure that staff is documenting appropriately.