Home Health Medical Review Top Denial Reason Codes

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.