CGS Continues Widespread
To: NHPCO Members
From: NHPCO Health Policy Team
Date: October 3, 2012
CGS Continues Widespread Edits for Hospice with ADR Requests
NHPCO met with CGS last week to discuss the numerous questions from provider members about the recent widespread edit announced by CGS. CGS has based their selection of edits on the data from claims, target areas identified by the OIG and review of aberrant billing and high risk claims. They agreed that the number and volume of widespread edits is high and is weighted to look at long stay patients. They stated that the average provider will have less than 10% of claims pulled for review.
Here are the widespread edits currently in place for providers who have CGS as their MAC:
Hospice Widespread Edits
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5101T |
This edit specifically targets Alzheimer’s disease, debility and COPD with a length of stay of 180 days or more. |
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5037T |
This edit selects hospice claims with revenue code 0651 (Routine) and a length of stay of greater than 730 days. |
|
5048T |
This edit selects hospice claims based on a length of stay of 999 days. |
|
5057T |
This edit selects hospice claims with revenue code 0656 (General Inpatient Services [GIP]) with at least seven or more days in a billing period. |
|
5091T |
This edit selects hospice claims with HCPC codes Q5003 (Hospice care provided in nursing long term care facility (LTC) or non-skilled nursing facility (NF)) and Q5004 (Hospice care provided in skilled nursing facility (SNF)), primary diagnosis of 799.3 (Debility, unspecified) and a length of stay greater than 180 days. |
|
5101T |
This edit selects claims with a length of stay greater than 180 days, and a primary diagnosis of 331.0 (Alzheimer’s disease), 799.3 (debility), or 496 (COPD) |
|
59BX9 |
This edit selects hospice claims due to previous denials for selected beneficiary. |
A hospice can track what widespread edits are in place by checking the CGS website.
CGS noted that prior to their taking over as the regional MAC, there had been fewer edits and reviews. CGS stated that their current efforts are in response to their own analysis of claims data and concerns.
Long Length of Stay
CGS reports that they are designing their edits on a review of data from hospice programs where the length of stay is substantially longer than it should be for a high percentage of patients. In our discussion, they stated:
“… patients have custodial needs, that is clear. However, the trajectory is not clear. CGS is looking for acuity to chart out the trajectory. Is this patient really at end stage? Is there decline? That description is not coming through on the documentation.”
There are hospices in the CGS jurisdiction that have 20-25% of their patients with a length of stay of 730 days or more. CGS states that they “need to determine whether these patients are chronically ill or terminally ill.”
CGS also provided more specifics about the ADR process and medical review in responding to NHPCO questions. The details follow.
Handling of Claims
- Leniency: If a provider is on a provider-specific edit, there can be some leniency to help the provider with cash flow. However, according to CGS, there is no option for leniency in the ADRs pulled for the widespread edits.
- Claim review volume: When asked about the volume of claims in medical review, CGS stated that they are "staffed up for the increased workload and that reviewsers have gone through extensive training."
- Timeliness of review: CGS does not anticipate going over the 60 day window for review of claims submitted.
- Reviewer missed information in the chart: If a reviewer misses a piece of documentation in the chart and issues a technical denial, the provider would go through the normal appeals process and CGS would handle the appeal as a reopening. Providers should include a cover letter with the documentation that clearly details where the documents are in the chart.
Provider ADR Submissions
- Due date for records: Send in the documentation as soon as it is ready, but no later than 30 days after requested. Reviews will be conducted on a first come, first serve basis. Early submission of documentation will likely facilitate early review and could help with cash flow and lower the impact that arises because of sequential billing.
- Cover letter: A cover letter that is submitted with the documentation is key. CGS staff describe it as a roadmap, which directs the reviewer to key technical documentation that will substantiate terminal diagnosis.
Medical Review So far NHPCO has heard from providers with questions about the following:
- Electronic signatures: CGS has posted a helpful tip sheet on signature requirements
- Interpretation of the LCDs - as guidelines or as requirements?
- Proof of IDT collaboration
- QIO decisions and their interaction with CGS claims submission
- Are there other issues your hospice has experiences? If so, tell us more at regulatory@nhpco.org
If there are questions, providers may call the CGS Provider Contact Center (PCC) about the ADR process or denied claims. Hospices should call 1-866-539-5592
We also would like to remind members about:
- NHPCO’s “Tips For Dealing With ADRs, Probe Edits, And The Medicare Appeals Process”
- NHPCO's "CGS - What Your Hospice Can Do"
- CGS’s description of the “Additional Development Request (ADR) Process.”
Additional Resources
- Program Integrity Manual (CMS Pub. 100-08) Ch. 3
- CMS Medicare Claim Review Programs: MR, NCCI Edits, MUEs, CERT, and RAC booklet
- FISS Guide, Chapter 3: Inquiry Menu, Accessing Additional Development Request Information section
Questions can be directed to NHPCO at regulatory@nhpco.org. Thank you.
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