Eli's Hospice Insider

Published on Thu Jun 18, 2015 PDF

Warning: Correcting the omission of the GW and GV modifiers may not be as easy as you think, MAC says.

Question: I didn’t include all the relevant diagnoses for our hospice patient on her claim. Do I have to file a redetermination?

Answer: HHH Medicare Administrative Contractor National Government Services “has received numerous appeal requests from hospice providers using the wrong appeals request form,” the MAC told providers in an email earlier this year. Fortunately, “failing to include all pertinent medical diagnoses” is one of the bases for using the much simpler “Medicare Part B Clerical Error/Omission Reopening Request Form,” NGS instructs. Other valid reasons for using this form include transposing numbers or entering an incorrect number of units.

However, be aware that if your claim was denied for any of the following reasons, you will have to file a redetermination, NGS stresses:

• Coverage/medical necessity of furnished items and service;

• Amount of the deductible and/or application of the coinsurance provision;

• Physician certification requirement;

• Determination with respect to the limitation of liability provision;

• Issue(s) affecting the amount of benefits payable (including over/underpayments);

• Prepay/postpay probes;

• CERT and RAC denials; or

• Adding or changing modifiers.

Hospices should note that the “adding or changing modifiers” reason does include leaving off the GV or GW modifier, NGS stressed. You can’t use the clerical error/omission form for forgetting the modifier. Instead, you must use the NGS redetermination form or the CMS-20027, the MAC directed.

“If an appeal is filed using the inappropriate form, the appeal will be dismissed,” NGS warned.