Home Health Service Denial and Action
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
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
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