How a Hospice Election Date Becomes an Automated Denial

Two months ago we counted the list CMS keeps of every topic a Recovery Auditor is cleared to review. It held 163 entries, and the companion list of what CMS was weighing next served no table at all, only the words "No data available."

The approved list reads 165 today. The proposed list has four rows on it, every one posted yesterday.

"Why does one date on a claim suddenly anchor three separate automated reviews?"

The Two That Landed Quietly

On September 24 CMS approved topics 0105 and 0163. Sort the list by date approved and they sit on top of it; the entry before them, anesthesia during spine pain management procedures, dates to July 15.

Topic 0105 is Physician Services Billed During Hospice: Unbundling. Review type automated, provider type Professional Services, every A/B MAC.

CMS describes it as services that "should be paid by the Hospice provider if services are related to the hospice beneficiary's terminal condition or if a physician is employed or paid under arrangement by the beneficiary's hospice provider."

Its affected-code field reads, in full: "All CPT/HCPCS codes that meet the approved selection criteria for review topic."

Topic 0163 is the ambulance version, same date, same review type, provider type Laboratory/Ambulance. Its code list is an actual list: A0426, A0427, A0428, A0429, A0433, A0434, with A0425 mileage riding along as a secondary code.

Then yesterday the proposed list came back. Four topics, all dated October 20, and one of them is 5A341, Home Health Services Related to Terminal Diagnosis Billed During a Hospice Episode of Care.

Automated, HHA MACs, affected codes given as revenue codes: 0023X, 042X, 043X, 044X, 055X, 023X, 056X, 057X.

Physician, ambulance, home health. Same rule, three provider classes, inside four weeks.

What the Edit Can Actually See

None of this is new law. Chapter 11 of the claims processing manual has carried the instruction since a 2020 revision: "For beneficiaries enrolled in hospice, A/B MACs (B) shall deny any services on professional claim that are submitted without either the GV or GW modifier."

Where it gets interesting is the sentence just above that one. The prepay edit runs on a presumption.

"A/B MACs (B) processing professional claims shall presume that hospice benefits are not involved unless the biller codes services on the claim to indicate that the patient is a hospice enrollee... or the trailer information on the CWF reply shows a hospice election."

So two things can stop a claim in front: you coded GV or GW yourself, or the Common Working File reply already carried an election trailer at the moment your claim adjudicated. Miss both and the claim pays clean, and it stays clean until somebody compares the two files later.

Section 50 reserved that second move years ago, for institutional claims carrying condition code 07 as well as professional ones carrying GW: contractors "may conduct pre-payment development or post-payment review to validate that services billed with the GW modifier or condition code 07 are not related to the patient's terminal condition."

An automated RAC topic is that sentence with a contractor's name attached. CMS is plain about what automated means: "Automated reviews occur at the system level while complex reviews require a qualified individual to review the medical record."

No Additional Documentation Request goes out. Nobody reads the note.

A date comparison and a modifier check, run against claims you were already paid for.