Pre-Payment Review Results for Hospice Provisional Period of Enhanced Oversight in Texas: January to March 2025

Published 04/22/2025

Pre-Payment Review Results for Hospice Provisional Period of Enhanced Oversight (PPEO) on New Hospices in Texas for January through March 2025

The Centers for Medicare & Medicaid Services (CMS) implemented the Probe and Educate process for Hospice PPEO on New Hospices in Texas. The reviews with edit effectiveness are presented here for Jurisdiction M.

Cumulative Results

Table 1. Cumulative Results.
Number of Providers with Edit Effectiveness Providers Compliant Completed/Removed Providers Non-Compliant Progressing to Subsequent Probe
18 12 6
Table 2. Cumulative Results.
Total Number of Claims with Edit Effectiveness Total Number of Claims Denied Overall Claim Denial Rate Total Dollars Reviewed Total Dollars Denied Overall Charge Denial Rate
101 30 30% $386,166.59 $140,485.83 36%

Probe One Findings

Table 3. Probe One Findings.
State Number of Providers with Edit Effectiveness Providers Compliant Completed Removed After Probe Providers Non-Compliant Progressing to Subsequent Probe
Texas 9 6 3
Table 4. Probe One Findings.
State Total Number of Claims with Edit Effectiveness Total Number of Claims Denied Overall Claim Denial Rate Total Dollars Reviewed Total Dollars Denied Overall Charge Denial Rate
Texas 52 15 29% $216,422.53 $66,301.16 31%

Probe Two Findings

Table 5. Probe Two Findings.
State Number of Providers with Edit Effectiveness Providers Compliant/Removed Providers Non-Compliant Progressing to Subsequent Probe
Texas 9 6 3
Table 6. Probe Two Findings.
State Number of Claims with Edit Effectiveness Number of Claims Denied Overall Claim Denial Rate Total Dollars Reviewed Total Dollars Denied Overall Charge Denial Rate
Texas 49 15 31% $169,744.06 $74,184.67 44%

Risk Category

The categories for Hospice PPEO on New Hospices in Texas are defined as:

Table 7. Risk Category.
Risk Category Error Rate
Minor 0–20%
Major 21–100%

Figure 1. Risk Category for Hospice PPEO on New Hospices in Texas.

Pie chart showing 67% Minor and 33% Major.

Top Denial Reasons

Table 8. Top Denial Reasons.
Percent of Total Denials Denial Code Denial Description Number of Occurrences
43% 5FF36, 5CF36 Documentation Submitted Does Not Support Prognosis of Six Months or Less 9
14% 56900 Requested Records Not Submitted Timely 3
10% 5TH99 Billing Error 2
5% 5FFTF, 5CFTF Face-to-Face Encounter Requirements Not Met 1
5% 5FFH9, 5CFH9 Physician Narrative Statement Not Present or Not Valid 1

Denial Reasons and Recommendations

5FF36/5CF36 — Documentation Submitted Does Not Support Prognosis of Six Months or Less 

Reason for Denial 
The claim has been fully or partially denied because the documentation submitted for review did not support prognosis of six months or less.

How to Avoid This Denial

  • Ensure a legible signature is present on all documentation necessary to support six-month prognosis
  • Submit documentation for review to provide clear evidence the beneficiary has a six-month or fewer prognoses which supports hospice appropriateness at the time the benefit is elected and continues to be hospice appropriate for the dates of service billed
  • Palmetto GBA has a Local Coverage Determination (LCD) for some non-cancer diagnoses
  • If documenting weight loss to demonstrate a decline in condition, include how much weight was lost over what period of time, past and current nutritional status, current weight and any related interventions
  • Document any comorbidity, which may further support the terminal condition of the beneficiary and the continuing appropriateness of hospice care

References

56900 — Auto Deny — Requested Records Not Submitted Timely

Reason for Denial
The services billed were not covered because the documentation was not received in response to the Additional Documentation Request (ADR) and therefore, we were unable to determine the medical necessity of the service billed. The provider has 45 days from the date the ADR was generated to respond with medical records. If less than 120 days after denial notification on the remittance advice, submit records to the contractor requesting records at the address listed on the original ADR to request reopening. Do not resubmit the claim.

How to Avoid This Denial

  • Be aware of the ADR date and the need to submit medical records within 45 days of the ADR date
  • Submit the medical records as soon as the ADR is received
  • Monitor the status of your claims in Direct Data Entry (DDE) and begin gathering the medical records as soon as the claim goes to the location of SB6001
  • Return the medical records to the address on the ADR. Be sure to include the appropriate mail code or station number. This ensures that your responses are promptly routed to the medical review department. Fax and electronic data submissions are also accepted as indicated on the ADR.
  • Gather all of the information needed for the claim and submit it all at one time
  • Attach a copy of the ADR request to each individual claim
  • If responding to multiple ADRs, separate each response and attach a copy of the ADR to each individual set of medical records. Make sure each set of medical records is individually identifiable and bound securely to ensure that no documentation is detached or lost. Do not use paper clips.
  • Do not mail packages collect on demand (COD); we cannot accept them

References

5TH99 — Billing Error

Reason for Denial
The services billed were not covered because the charges were billed in error.

How to Avoid This Denial

  • Ensure accuracy of billing prior to submitting the claim(s) to Medicare
  • Submit a corrected UB92 with an 817 or 827 bill type when billing errors are discovered by the hospice agency. If the claim has been selected for medical review, submit the hardcopy corrected UB92 with the records to Palmetto GBA.

Reference: CMS IOM, Pub. 100-04, Medicare Claim Processing Manual, Chapter 11, Section 30.3 (PDF).

5FFTF/5CFTF — Face-to-Face Encounter Requirements Not Met

Reason for Denial
The services billed were not covered because the documentation submitted for review did not include documentation of a face-to-face encounter.

How to Avoid This Denial
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. 

  • 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 separate and distinct section of, or an addendum to, the recertification form, must be clearly titled
  • When a nurse practitioner or non-certifying hospice physician 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

References

5FFH9/5CFH9 — Physician Narrative Statement Not Present or Not Valid

Reason for Denial
The claim has been denied as the physician narrative statement is not present or not valid.

How to Avoid This Denial

  • The physician must include a brief narrative explanation of the clinical findings that supports a life expectancy of six months or less as part of the certification and recertification forms, or as an addendum to the certification and recertification forms
  • If the narrative is part of the certification or recertification form, then the narrative must be located immediately prior to the physician’s signature
  • If the narrative exists as an addendum to the certification or recertification form, in addition to the physician’s signature on the certification or recertification form, the physician must also sign immediately following the narrative in the addendum
  • The narrative shall include a statement directly above the physician signature attesting that by signing, the physician confirms that he/she composed the narrative based on his/her review of the patient’s medical record or, if applicable his or her examination of the patient
  • The narrative must reflect the patient’s individual circumstances and cannot contain check boxes or standard language used for all patients

References

Education
Palmetto GBA offers providers selected for TPE an individualized education session to discuss each claim denial. This is an opportunity to learn how to identify and correct claim errors. A variety of education methods are offered such as webinar sessions, web-based presentations or teleconferences. Other education methods may also be available. Providers do not have to be selected for TPE to request education. If education is desired, please complete the Education Request Form (PDF). 

Next Steps
Providers found to be non-compliant (major risk category/denial rate of 21–100 percent) at the completion of PPEO Probe 1 will advance to Probe 2, and providers found to be non-compliant (major risk category/denial rate of 21–100 percent) at the completion of PPEO Probe 2 may potentially advance to a subsequent Probe for TPE after at least 35 days from issuance of results letter.


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