North Carolina Hospice CERT Data 2018

The following information was pulled from PalmettoGBA Article:  North Carolina Hospice CERT Data (see attached related links)

The Comprehensive Error Rate Testing (CERT) program looks for improper payments on Medicare claims. Based on the 2018 annual report, here is the hospice CERT information for North Carolina.

  • Total claims reviewed: 27
  • Total dollars reviewed: $90,375.65
  • Claims paid: 22 
  • Dollars paid: $74,294.40
  • Claims denied: 5
  • Dollars denied : $16,081.25
  • Claims with error code No Documentation (16): 1
  • Claims with error code Insufficient Documentation (21): 1
  • Claims with error code Not Medically Necessary (25): 1

CERT Reviewer Error: 16 — No Documentation
Error Subcategory Details:

  • RP — No Records Found for DOS: Note from hospital stating, “We show no treatment at this facility for the dates of service you requested.”

Here are some tips to prevent this error:

  • Make sure the date(s) of service are documented
  • Ensure the proper principle diagnosis and principle procedure is coded correctly
  • Include all documentation to support the codes billed
  • Use a checklist to ensure all of the essential pieces are included in the record
  • Make sure that both sides of double sided documents are submitted
  • Remember it is the billing provider’s responsibility to obtain and necessary information required for the record review, regardless of the location of the documentation

CERT Reviewer Error: 21 — Insufficient Documentation
Error Subcategory Details:

  • 00195 — Hospice — Physician Narrative as Part of Certification/Recertification: Authenticated IDG POC reviews/updates, prior to 08/11/XX, and including 08/25/XX, that documents discussion with physician in attendance, and includes signatures of attendees
  • SQ — Hospice — MD Certification/Recertification: Valid hospice physician’s certification of terminal illness with narrative statement for benefit period 07/07/XX thru 09/04/XX.

Here are some tips to prevent this error:

1. Make sure the following information is submitted in the record for review:

  • Hospice election information
  • Identification of the particular hospice that will provide care to the individual
  • The individual’s or representative’s (as applicable) acknowledgment that the individual has been given a full understanding of hospice care, particularly the palliative rather than curative nature of treatment
  • The individual’s or representative’s (as applicable) acknowledgment that the individual understands that certain Medicare services are waived by the election
  • The effective date of the election
  • The signature of the individual or representative
  • The plan of care (POC), which is reviewed, revised and documented as frequently as the beneficiary's condition requires, but no less frequently than every fifteen (15) calendar days
  • The face-to-face encounter must occur no more than 30 calendar days prior to the start of the third benefit period and no more than 30 calendar days prior to every subsequent benefit period thereafter. Specific documentation related to face-to-face encounter requirements must be submitted for review. This includes, but is not limited to, the following:
    • The hospice physician or nurse practitioner who performs the encounter must attest in writing that he or she had a face-to-face encounter with the patient, including the date of the encounter
    • The attestation, its accompanying signature and the date signed must be a separate and distinct section of, or an addendum to, the recertification form, and must be clearly titled
    • When a nurse practitioner performs the encounter, the attestation must state that the clinical findings of that visit were provided to the certifying physician for use in determining whether the patient continues to have a life expectancy of six months or less, should the illness run its normal course

2. Comprehensive assessment:

• Physician Certification
• Signed and dated
• Reference to the benefit period
• Verbal certification included, if applicable
• Documentation that medical director is the attending, if applicable
• Narrative/face-to-face encounter narrative
• Documentation of clinical findings
• Attestation

CERT Reviewer Error: 25 — Not Medically Necessary 
Error Details:

Hospice Services Not Reasonable and Necessary:

  • The documentation does not support a terminal prognosis. The beneficiary is stable with chronic conditions; no evidence of decline or significant progression of condition.

Here are some tips to prevent this error:

Documentation to support terminal prognosis (example may include):

  • History
  • Progression of illness/disease
  • Recent changes
  • Exacerbation of symptoms
  • Comorbidities
  • Secondary conditions
  • Variables that are measureable
  • Labs
  • PPS/Karnofsky scale
  • FAST scale for Alzheimer’s patients
  • Weight loss
  • BMI
  • Percentage of meals eaten
  • Vital signs
  • IDG meeting notes