Update: Post Payment Medical Review Topics

POSTED ON MONDAY, August 31, 2020

CMS authorized the resumption of medical reviews to begin in August. Since the original resumption announcement, hospices and home health agencies have learned that medical reviews administered by the Medicare Administrative Contractors will be service-specific post payment reviews. NOTE: Targeted Probe & Educate reviews, suspended early in the current Public Health Emergency, are not resuming at this time and a future resumption date has not been set.

“Providers should continue to respond to ADRs within 30 days if at all possible, but must have documentation submitted within 45 days. MACs have 60 days to review responses to post payment ADRs.





Medical necessity

Edit: 5L000

This review selects any home health claim with 2 to 6 visits and a diagnosis code of I11.0, Z46.6, J44.1, I10, J44.9, G20, I25.10, N39.0, J18.9, or I87.2 submitted with dates of service prior to March 1, 2020



Home Health PDGM

Edit: 5AAGP

Bill type:  32X or 33X

reviewing claims billed under PDGM 1/1/2020 – 2/29/2020



Home Health PDGM


Bill type: 329

Reviewing claims billed under PDGM 1/1/2020 – 2/29/2020



Eligibility and medical necessity      

Review of inpatient claims submitted for home health services for eligibility and medical necessity





CGS is starting with home health medical reviews and do not know when the hospice reviews will begin.  We will provide an update when it is available.



Hospice length of stay greater than 730 days

Edit:  5ANKP

Bill Type = 81X or 82X



General Inpatient Care (GIP) 7 or more days

Edit: 5FGFP

Bill Type = 81X, 82X

Revenue Code: 0656



General inpatient care (GIP)  7 or more days          

Revenue code: 656

Place of service codes Q5004–Q5009


Source: NAHC Report

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