Description
This review will determine if Hospice General Inpatient Care (GIP) was reasonable and necessary to achieve pain control or acute or chronic symptom management which could not be managed in any other setting. Claims that do not meet the indications of coverage and/or medical necessity will be recoded to Routine Hospice Care 0651 and result in an overpayment.
Affected Codes
REV. Code 0656 – General Inpatient Care
Applicable Policy Codes
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, §1834(m)- Payment of Benefits
8. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §§1861(u)- Provider of Services and (dd)- Hospice Care; Hospice Program
9. 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
10. 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
11. 42 CFR §405.929- Post-Payment Review
12. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
13. 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
14. 42 CFR §405.986 - Federal Health Insurance for The Aged and Disabled, Good Cause for Reopening
15. 42 CFR §411.15(k)(2) - Exclusions from Medicare and Limitations On Medicare Payment, Particular Services Excluded from Coverage
16. 42 CFR §418– Hospice Care
17. 42 CFR §424.5(a)(6)- Basic Conditions
18. 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
19. Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4, §60- Certification and Recertification by Physicians for Hospice Care
20. Medicare Benefit Policy Manual, Chapter 9, §10- Requirements—General; §20-Certification and Election Requirements; §40-Benefit Coverage
21. Medicare Benefit Policy Manual Chapter 9, §40.1.5- Short-Term Inpatient Care
22. Medicare Claims Processing Manual, Chapter 1, §60.4.1- Outpatient Billing with an ABN (Occurrence Code 32)
23. Medicare Claims Processing Manual, Chapter 11, §30- Billing and Payment for General Hospice Services
24. Medicare Claims Processing Manual Chapter 11, §100- Billing for Hospice Denials
25. Medicare Claims Processing Manual, Chapter 30, §50- Advance Beneficiary Notice of Non-coverage (ABN)
26. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
27. CGS Local Coverage Determination L34538- Hospice Determining Terminal Status; Effective 10/01/2015, Revised 07/06/2023
28. NGS Local Coverage Determination L33393 Hospice- Determining Terminal Status; Effective 10/01/2015; Revised 11/14/2019
29. NGS Local Coverage Article A52830 Billing and Coding: Hospice: Determining Terminal Status; Effective 10/01/2015; Revised 11/14/2019
30. HCPCS Level II Codebook