Home Health Medical Review Top Denial Reason Codes - how to prevent the denial

Palmetto GBA encourages all providers to review this information when filing claims to prevent denials and to ensure their claims are processed timely.

Face to Face Encounter Requirements Not Met
The services billed were not covered because the documentation submitted for review did not include (adequate) documentation of a face-to-face encounter.

To prevent this denial: The face-to-face encounter must occur no more than 90 days prior to the home health start of care date or within 30 days after the start of care.

Specific documentation related to face to face encounter requirements must be submitted for review. This includes, but is not limited to, the following:
•    The certifying physician must document that he/she or an allowed non-physician practitioner (NPP) had a face-to-face encounter with the patient, including the date of the encounter
•    The documentation of the encounter must include a brief narrative, composed by the certifying physician, describing how the patient’s clinical condition as observed during that encounter supports the patient’s homebound status and need for skilled services
•    The certifying physician must document the encounter either on the certification, which the physician signs and dates, or on a signed addendum to the certification
•    The certifying physician may dictate the face-to-face encounter documentation content to one of the physician’s support personnel to type. The documentation may also be generated from a physician’s electronic health record.

Partial Denial for Therapy Resulting in Medical Review HIPPS Code Change
The services billed were paid at a lower payment level. Based on medical review, the original HIPPS code was changed.

To prevent this denial:
•    Under the Prospective Payment System (PPS), Medicare reimbursement rates are based on the patient’s health condition and care needs. In order to receive a higher level of payment based on therapy services, there should be an adequate number of payable therapy visits to meet the threshold. This may include one type of therapy or a combination of occupational, speech-language pathology, or physical therapy services.
•    Based on the medical records submitted for review, some of the therapy visits were not allowed and reimbursement was adjusted due to a partial denial.

Auto Deny - Requested Records Not Submitted
Medical records were not received in response to an Additional Documentation Request (ADR) in the required time frame; therefore, we were unable to determine medical necessity.

To prevent this denial:
•    Monitor your claim status on Direct Data Entry (DDE). If the claim is in status/location SB6001, the claim has been selected for review and records must be submitted
•    Be aware of the need to submit medical records within 30 days of the ADR date. The ADR date is in the upper left corner of the ADR request
•    Gather all information needed for the claim and submit it all at one time
•    Submit medical records as soon as the ADR is received
•    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. Ensure each set of medical records is bound securely so the submitted documentation is not detached or lost.
•    Do not mail packages C.O.D.; we cannot accept them.
•    Return the medical records to the address on the ADR. Be sure to include the appropriate mail code. This ensures your responses are promptly routed to the Medical Review Department


Information Provided Does Not Support the Medical Necessity for This Service
This claim was fully or partially denied because the clinical documentation submitted for review did not support the medical necessity of the skilled services billed. For example, the submitted documentation may have indicated there was no longer a reasonable potential for change in the medical condition, or sufficient time had been allowed for teaching or observation of response to treatment. 

To prevent this denial:
•    Submit all documentation related to the services rendered and billed to Medicare which supports the medical necessity of the services. Note – A legible signature is required on all documentation necessary to support orders and medical necessity.
•    Use the most appropriate ICD-9-CM codes to identify the beneficiary’s medical diagnosis/diagnoses
•    Submit documentation to support the need for skilled care. Some reasons for services may include, but are not limited to, the following:
1.    New onset or acute exacerbation of diagnosis (Include documentation to support signs and symptoms and the date of the new onset or acute exacerbation)
2.    New and/or changed prescription medications - New medications: those the beneficiary has not taken recently, i.e., within the last 30 days. Changed medications: those, which have a change in dosage, frequency, or route of administration within the last 60 days.
3.    Hospitalizations (include date and reason)
4.    Acute change in condition (Be specific and include changes in treatment plan as a result of changes in medical condition, e.g., physician contact, medication changes)
5.    Changes in caregiver status or an unstable caregiving situation (e.g., involvement of many services or community resources, unsafe or unclean environment which interferes with putting the plan into action)
6.    Complicating factors (i.e., simple wound care on lower extremity for a beneficiary with diabetic peripheral angiopathy)
7.    Inherent complexity of services; therefore, the services can be safely and effectively provided only by a skilled professional
8.    Lack of knowledge or understanding of the beneficiary’s care, which requires initial skilled teaching and training of a beneficiary, the beneficiary’s family or caregiver on how to manage the beneficiary’s treatment regime
9.    Reinforcement of previous teaching when there is a change in the beneficiary’s physical location (i.e., discharged from hospital to home)
10.    Any type of re-teaching due to a significant change in a procedure, the beneficiary’s medical condition, when the beneficiary’s caregiver is not properly carrying out the task, or other reasons which may require skilled re-teaching and training activities
11.    The need for a nurse to administer an injection of a self-injectable medication such as insulin or Calcimar. Clinical documentation needs to indicate: (a) the beneficiary’s inability to self-inject and the non-availability of a willing/able caregiver, (b) the appropriate diagnosis to warrant administration of the medication, (c) laboratory results (if required to meet Medicare criteria), and (d) dosage of the medication.
12.    The need for foley/suprapubic catheter changes and/or assessment/instruction regarding complications
13.    The need for gastrostomy tube changes and/or assessment/instruction regarding complications
14.    The need for administration of IM/IV medications based on medical necessity, supporting diagnosis, and accepted standards of medical practice
15.    Dressing changes for complicated wound care including documentation (at least weekly) of wound location, size, depth, drainage, and complaints of pain
16.    The need for management and evaluation of a complex care plan. Answering “yes” to the following questions may be helpful in determining this need:

•  Is the patient at high risk for hospitalization or exacerbation of a health problem if the plan of care is not implemented properly (e.g., multiple medical problems or diagnosis, limitations in activities of daily living or mental status, cultural barriers, history of repeated hospitalizations)?
• Does the patient have a complex unskilled care plan (e.g., many medications, treatments, use of complex or multiple pieces of equipment, unusual variety of supplies)?
• Is there an unstable caregiving situation (e.g., involvement of many services or community resources, unsafe or unclean environment that interferes with putting the plan into action)?
• Does it require the skills of a registered nurse or a qualified therapist to ensure safe and appropriate implementation of the plan of care?

5DOW4 – Partial Denial Resulting in a LUPA
Based on the medical records submitted for review, a portion of the services provided was denied. This resulted in a Low Utilization Payment Adjustment (LUPA).A LUPA is an episode with four or fewer visits. The payments are based on the wage adjusted per visit amount for each of the visits rendered instead of the full episode amount.

To prevent this denial:
Ensure the documentation submitted for review supports all criteria for all services billed.
 
Unable to Determine Medical Necessity of HIPPS Code Billed as Appropriate OASIS Not Submitted
The services billed were not covered because the home health agency did not submit the OASIS to the State repository for the HIPPS code billed on the claim. The provider should ensure that the OASIS that generated the HIPPS code for the claim is submitted to the state repository and submitted with the medical records in response to an ADR.

To prevent this denial:
Under the HHPPS, an OASIS is a regulatory requirement. If the home health agency does not submit the OASIS, the medical reviewer cannot determine the medical necessity of the level of care billed and no Medicare payment can be made for those services.

Physician's Plan of Care and/or Certification Present - Signed but Not Dated

Physician's Plan of Care and/or Certification Present - No Signature

No Plan of Care or Certification
The services billed were not covered because the home health agency (HHA) did not have the plan of care established and approved by a physician, as required by Medicare, included in the medical records submitted for review and/or the service(s) billed were not covered because the documentation submitted did not include the physician’s signed certification or recertification.

To prevent this denial:
•    Ensure that the appropriate plan of care (POC) is included and that it is legibly signed and dated by the physician prior to billing
•    A plan of care refers to the medical treatment plan established by the treating physician with the assistance of the home health skilled professional. The plan of care contains all pertinent diagnoses, the patient’s mental status, the types of services, supplies, and equipment required, the frequency of visits to be made, prognosis, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, all medications and treatments, safety measures to protect against injury, instructions for timely discharge or referral and any additional items the HHA or physician chooses to include.
•    Ensure that the signed certification or recertification is submitted when responding to an ADR
•    The physician must certify that:
o    The home health services were required because the individual was confined to his/her home and needs intermittent skilled nursing care, physical therapy and/or speech-language pathology, or continues to need occupational therapy;
o    A plan for furnishing such services to the individual has been established and is periodically reviewed by a physician; and
o    The services were furnished while the individual was under the care of a physician
•    Since the certification is closely associated with the POC, the same physician who establishes the plan must also certify to the necessity for home health services. Certifications must be obtained at the time the plan of care is established or as soon thereafter as possible. There is no requirement that a specific form must be used, as long as the intermediary can determine that this requirement is met. When requesting reimbursement for a claim, the provider must have the certification on file and be able to submit this information if medical records are requested by the intermediary.
•    The physician must recertify at least once every 60 days that there is a continuing need for services and should estimate how long services will be needed. The recertification should be obtained at the time the POC is reviewed and must be signed by the same physician who signs the plan of care. When requesting reimbursement for a claim, the provider must have the recertification on file and be able to submit this information if medical records are requested by the intermediary.

Medical Review HIPPS Code Change/Documentation Contradicts MO/M Item(s)
The services billed were paid at a different payment level. Based on medical review, the original HIPPS code was changed. To avoid changes for this reason, the documentation should paint a consistent picture of the patient’s condition.

Under the Prospective Payment System (PPS), Medicare reimbursement rates are based on patient's health condition and care needs. The medical documentation submitted contradicted your response to one or more of the Outcome and Assessment Information Set (OASIS) items. As a result, reimbursement has been adjusted.

Services Billed Were More Than Ordered
The submitted physician’s orders for services did not cover all of the visits billed. An example of this is when physician’s orders were submitted for seven physical therapy visits; however, 10 were billed. If orders do not cover the visits billed or visits need to be added, submit a corrected, hardcopy UB-04 with a 337 or 327 bill type with the medical records.

To prevent this denial:

In order to avoid unnecessary denials for this reason code, ensure that the physician’s orders (1) include a legible physician signature dated prior to billing Medicare, and (2) cover the services to be billed. The Medicare program requires that the physician order all services and that a plan of care is set up for furnishing services. When responding to an ADR, do the following:

•    Ensure that all orders for services billed are included with the medical records
•    A legible signature is required on all documentation necessary to support orders and medical necessity