Posted on Monday, October 19, 2020
Beginning October 2020 CGS initiated a hospice post payment review of general inpatient (GIP) claims 7 days or longer that were submitted prior to March 1, 2020. The GIP > 7 days review affects any hospice claim with the revenue code 0656.
Corridor is encouraging hospice providers to be alert to notices from your MAC intermediary (CGS) which will be sent in the mail and will be posted in your website CGS portal where you file claims. Don’t throw out that envelope from CGS just because you think it looks unimportant. And when you are in the claims portal, look for information about claims CGS has identified for a post payment medical review. Your response must be submitted in a timely manner. Ignoring their requests won’t make them go away!
What Triggers a Review?
The GIP level of care for symptom management is a valuable tool for pain control or symptom management which cannot be managed in other settings. It is intended for short term interventions in a setting with 24-hour skilled RN support. CMS expects that symptoms can be controlled within 48 – 72 hours in a GIP setting. When CGS has flagged a claim for review, you must submit all records to support the GIP level of care.
It is important to understand why the claim is being questioned so you can correctly respond to the Additional Documentation Request (ADR). If your claim is denied, you can lose the reimbursement, and if your claim failures are numerous CGS may escalate their reviews. Remember, CGS reviews the record in its entirety so all billing requirements must be met. CGS reviews for technical requirements as well as clinical supporting documentation.
The five top reasons you may receive a denial are:
- The information provided doesn’t support a terminal prognosis of 6 months or less.
- The Notice of Election is invalid due to missing or incorrect basic information such as the name of the patient, the signature of the legal representative or the dates don’t match so that the NOE does not meet statutory or regulatory requirements.
- The physician narrative statement must be a true clinical narrative from the physician.
- Face to face encounter requirements aren’t met.
- GIP level of care wasn’t reasonable or necessary because the documentation does not support the claim that symptoms could not be controlled at home.
How Corridor Can Help
Whether you have already received a notice that your GIP 0656 claims will be reviewed or if you anticipate your caseload may trigger such a review, Corridor can identify areas that may require your attention before you respond to an ADR to ensure you submit documentation that will meet the CMS inquiry. If you have already submitted your documentation, Corridor can help you with an appeals process if that becomes necessary by assembling the correct information to support your case and providing expertise for your response letter.
Yes, 2020 has thrown a lot at all of us. So, if you receive a GIP notice of medical review, give us a call before you submit your records. We can cut through the paperwork for you and help you complete a successful ADR submission or appeal.
Click Here to learn more about our Clinical Documentation Advisory Services.
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