To:       NHPCO Members
From:  NHPCO Health Policy Team
Date:   September 27, 2012

CGS Government Administrators Probe Edit

CGS Government Administrators, LLC (CGS) has implemented a widespread probe edit for hospice providers in its jurisdiction. Claims for debility, Alzheimer’s disease and Chronic Airway Obstruction have been selected for medical review.  CGS is basing this probe edit on the analysis of errors related to the widespread probe for claims selected for medical review between October 20, 2011 and March 31, 2012.   

NHPCO has heard from many provider members who have received ADRs due to this edit and want to assure hospice providers in the CGS jurisdiction that we are proactively responding to CGS with provider concerns and the edit’s impact on hospice operations. 

CGS has posted on their webpage the top reasons for denial for ADR reviews.  The top two are: 

1. Six-month terminal prognosis not being supported in the medical record documentation “an individual is eligible for the Medicare hospice benefit when that individual has a terminal illness with a life expectancy of six months or less if the terminal illness runs its normal course.  The LCD for “Hospice - Determining Terminal Status” L32015, contains guidelines for hospice coverage for patients, and provides some documentation suggestions related to documenting terminal status. The patient’s appropriateness for the hospice benefit must be clearly supported in the medical record from admission and throughout the hospice care provided.”
2. Missing, incomplete or untimely certifications
   1. Medical records to support the services billed in response to the additional development request (ADR) were not submitted and/or the records were not received timely.
   2. Providers have 30 days to respond and submit the information requested on the ADR.  If a provider does not respond, the entire claim is automatically denied on the 46th day with the denial reason code 56900

Things your hospice can do:

1. Monitor the CGS website for announcements about widespread edits.
2. Monitor the FISS system at least once a week for claims with a status/location of “S B6001” which indicates that an ADR request has been generated.
3. When an ADR request has been made, pay special attention to the response deadline – no later than 30 days after the request date.  CGS medical review clinicians have 60 days to review the documentation and make a determination about payment.
4. If the claim is either partially or fully denied, the appeal must be filed within 120 days.

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” (PDF)
• and CGS’s description of the “Additional Development Request (ADR) Process.”

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 should be directed to regulatory@nhpco.org

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