Description
This review will determine if hospice Continuous Home Care services were reasonable and necessary to achieve palliation and management of the patient’s acute medical symptoms to maintain the terminally ill patient at home, based on the documentation in the medical record.
Affected Code(s)
REV Codes 0652
HCPCS G0299, G0300, G0156
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) and (a)(1)(C)- Exclusions from Coverage and Medicare as Secondary Payer
9. 42 CFR §405.929- Post-Payment Review
10. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
11. 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
12. 42 CFR §405.986 - Good Cause for Reopening
13. 42 CFR § 411.15(k)(2) - Particular Services Excluded from Coverage
14. 42 CFR § 418.22 - Certification of terminal illness
15. 42 CFR § 418.24 - Election of hospice care
16. 42 CFR § 418.56 Condition of participation: Interdisciplinary group, care planning, and coordination of services
17. 42 CFR, § 418.204(a) Special coverage requirements; Periods of crisis.
18. 42 CFR, § 418.302 - Payment, Procedures for hospice care.
19. 42 CFR, § 424.5(a)(6) – Basic Conditions, Sufficient Information
20. Medicare General Information, Eligibility and Entitlement Manual, Chapter 4 - Physician Certification and Recertification of Services, Section 60- Certification and Recertification by Physicians for Hospice Care
21. Medicare General Information, Eligibility and Entitlement Manual, Chapter 5 - Definitions, Section 60 - Hospice Defined
22. Medicare Benefit Policy Manual, Chapter 9 - Coverage of Hospice Services Under Hospital Insurance, Section 10- Requirements—General
23. Medicare Benefit Policy Manual, Chapter 9 - Coverage of Hospice Services Under Hospital Insurance, Section 20- Certification and Election Requirements
24. Medicare Benefit Policy Manual, Chapter 9 - Coverage of Hospice Services Under Hospital Insurance, Section 40- Benefit Coverage
25. Medicare Benefit Policy Manual, Chapter 9 - Coverage of Hospice Services Under Hospital Insurance, Section 50- Limitation on Liability for Certain Hospice Coverage Details
26. Medicare Benefit Policy Manual, Chapter 9 - Coverage of Hospice Services Under Hospital Insurance, Section 80- Hospice Pre-election evaluation and counseling services
27. Medicare Claims Processing Manual, Chapter 11- Processing Hospice Claims
28. Medicare Claims Processing Manual, Chapter 30 - Financial Liability Protections, §Section 50- Advance Beneficiary Notice of Non-coverage (ABN)
29. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §3.1- 3.6.6