Description
This review will determine if billed Hospice Care with Extended Lengths of Stay was reasonable and necessary. Claims that do not meet the indications of coverage and/or medical necessity will be denied and result in an overpayment.
Affected Code(s)
• 0651- Routine Home Care
• 0652- Continuous Home Care
• 0655- Inpatient Respite Care
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §§1812(a)(4), (a)(5), and (d)- Scope of Benefits.
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1813(a)(4)(A)- Deductibles and Coinsurance.
3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1814(a)(7)- Conditions of and Limitations on Payment for Services.
4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1814(i)(1)(A)- Payment for Hospice Care.
5. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §§1815(a) and (e)(2)(D)- Payment to Providers of Services.
6. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e)- Payment of Benefits.
7. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §§1861(u)- Provider of Services and (dd)- Hospice Care; Hospice Program.
8. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A), (a)(1)(C), (a)(6), and (a)(9)- Exclusions from Coverage and Medicare as Secondary Payer
9. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1879 (g)(2)- Limitation of Liability of Beneficiary Where Medicare Claims are Disallowed.
10. 42 CFR §405.929- Post-Payment Review.
11. 42 CFR §405.930- Failure to Respond to Additional Documentation Request.
12. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
13. 42 CFR §405.986 - Federal Health Insurance for The Aged and Disabled, Good Cause for Reopening.
14. 42 CFR, §411.15(k)(2) - Exclusions from Medicare and Limitations On Medicare Payment, Particular Services Excluded from Coverage.
15. 42 CFR §418– Hospice Care.
16. Medicare General Information, Eligibility, and Entitlement Manual, Chapter 1, §10- General program Benefits, §10.1- Hospital Insurance (Part A) for Inpatient Hospital, Hospice, Home Health and Skilled Nursing Facility (SNF) Services - A Brief Description.
17. Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4, §60- Certification and Recertification by Physicians for Hospice Care.
18. Medicare General Information, Eligibility and Entitlement Manual, Chapter 5, §60 - Hospice Defined.
19. Medicare Benefit Policy Manual, Chapter 9, §§10- Requirements—General; 20- Certification and Election Requirements; 30.2- Respite Care Coinsurance; 40- Benefit Coverage; 50- Limitation on Liability for Certain Hospice Coverage Denials ; 80- Hospice Pre-election evaluation and counseling services; 90- Caps and Limitations on Hospice Payments.
20. Medicare Claims Processing Manual Chapter 11, §30- Billing and Payment for General Hospice Services.
21. Medicare Claims Processing Manual Chapter 11, §100- Billing for Hospice Denials
22. Medicare Claims Processing Manual, Chapter 30, §50- Advance Beneficiary Notice of Non-coverage (ABN).
23. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
24. CGS Administrators, LLC, LCD L34538- Hospice Determining Terminal Status; Effective 10/01/2015; Revised 07/06/2023.
25. National Government Services, Inc., LCD L33393 Hospice Determining Terminal Status; Effective 10/01/2015; Revised 11/14/2019.
26. National Government Services, Inc., LCA A52830 Billing and coding: Hospice: Determining Terminal Status; Effective 10/01/2015; Revised 11/14/2019
27. CMS, Hospice: CMS Flexibilities to Fight Covid-19, Revised 05/10/2023. Hospice: CMS Flexibilities to Fight COVID-19