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.
HOME HEALTH
CGS
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
NGS JK
Home Health PDGM
Edit: 5AAGP
Bill type: 32X or 33X
reviewing claims billed under PDGM 1/1/2020 – 2/29/2020
NGS J6
Home Health PDGM
Edit: 5WGMP/5CGMP
Bill type: 329
Reviewing claims billed under PDGM 1/1/2020 – 2/29/2020
Palmetto
Eligibility and medical necessity
Review of inpatient claims submitted for home health services for eligibility and medical necessity
HOSPICE
CGS
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.
NGS JK
Hospice length of stay greater than 730 days
Edit: 5ANKP
Bill Type = 81X or 82X
NGS J6
General Inpatient Care (GIP) 7 or more days
Edit: 5FGFP
Bill Type = 81X, 82X
Revenue Code: 0656
Palmetto
General inpatient care (GIP) 7 or more days
Revenue code: 656
Place of service codes Q5004–Q5009
Source: NAHC Report
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