During January to March of this year, the top reasons for denial for Home Health Palmetto GBA claims were published on their website as listed below. They can be confusing in their meaning and so we have attempted to clarify as we understand them. Without further ado:
56900—Medical Records not received
This has been the number one reason for denials for years. This occurs most often when an ADR is not seen in the system. Alternatively, it is noticed too late to get records together and sent. To avoid this denial:
CGS encourages providers to use the Fiscal Intermediary Standard System (FISS) to check for MR ADRs at least once per week. To check for MR ADRs,
in the FISS system:
- Use Option 12
- Enter your NPI number and status/location of ‘S B60001’
- ADRs will appear as reason code 39700
- The ADR date is in the upper left corner. 45 days from the date of the ADR
date the claim will auto cancel.
In addition to the above, we suggest:
- Uploading the documents when you are able.
- Mail the documents with proof of delivery requested.
- Track delivery.
- Retain copies of everything including the completed ADR. If you sent by overnight mail five days before the due date and the records are not there two days later, you will have the opportunity to resend.
- Use the address and mail code on the ADR. This is on the last page of the printed document and may differ from the return address on the first page.
- Print the ADR from the computer and include a copy with Your submitted documentation.
5FF2F Face to Face Requirements not Met
This should be easy by now but it’s still confusing. Our favorite cheat sheet is the PDF on CGS’s website. Additionally, we see denials that can be prevented by being mindful of the following:
- Regardless of the episode within the sequence of multiple episodes, the Face-to-Face document must be included even if it occurred six or more months ago.
- The physician clinic visit or hospital documentation will be used to establish eligibility.
- If the information sent by the doctor does not clearly indicate that the patient is confined to the home or the need for skilled services, the agency can supplement the information. Here’s how. Send you Admission OASIS to the physician with a request to sign and date it, make a copy, file one in his records and return the copy to you.
- Teach everyone in the agency how to evaluate Face-to-Face documents. You should never come into contact with one without reviewing it.
5F023 No Plan of Care
It is a rare event that an agency omits the plan of care from an ADR. When an ADR is denied for not having the plan of care, agencies often assume that the mistake is on the part of the reviewer. Look again. Often this means:
- The plan of care was not signed.
- The plan of care was signed by a Nurse Practitioner or Physician Assistant
- A different physician than the one listed on the plan of care signed it.
- The signature was not dated although there is a seperate code for this.
- The date of the signature was after the date of billing.
5CHG3 Partial Denial of Therapy
A reviewer will often deny visits based upon an arbitrary number of feet that a patient can walk or problems with individual notes. Because therapy adds significantly to the dollar amount of a claim, these services are an opportunity for Medicare contractors to save a few Medicare dollars at your expense. To avoid these denials:
- Document not only how far the patient ambulated but how they tolerated the ambulation.
- Take pre and post vital signs. Document balance and gait disturbances.
- Always document pain and discomfort in quantitative measures.
- Document any complaints or new orders not related to therapy and report them to the case manager. Follow up in writing.
- Most importantly, request a case conference and schedule discharge when the patient no longer needs therapy.
5FNOA – Appropriate OASIS not submitted
This code means that the OASIS was not found in the repository when the claim was billed. Palmetto GBA explains this denial code as follows:
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.
Since this list was generated from 2018 claims, it is unlikely that agencies would receive this denial code in response to an ADR because they are auto-rejected upon dropping the claim. Yet, this reason for denial is ranked fifth. If you have received a denial for reason code 5FNOA in response to records submitted in response to an ADR, please let us know.
5T072 – No physician Orders for Services
This denial refers to services provided in excess of what the MD ordered, or services provided before an order was obtained. This is frequently seen when a physician orders PT to evaluate the patient but there are no subsequent orders. It may also be related to the date next to the nurse’s signature on the plan of care. Nurses new to reviewing and signing plans of care will often date their signature with the date that the document was signed instead of the verbal SOC date.
To prevent this denial:
- If possible (and it should be possible), include therapy frequency on the plan of care.
- Consider amending your standard therapy contract to state that the agency will not pay for unauthorized visits.
- If the therapist includes the frequency and goals on the evaluation and that is signed by the MD, make a second copy to include with orders when an ADR is received.
- Educate and spot check the POCs of new case managers. If a plan of care is not complete by the first day of the episode and the nurse contemporaneously dates his signature, all days prior to the date indicated are not billable as there are no signed orders.
- The same signature and dating rules apply to MD signatures on interim orders.
- The correct way to write an order that was received earlier is:
- Date the document on the day it was written
- Begin the order with, ‘Effective on (the date you received the order)
- Date your signature when you signed the document.
5F041-Information does not support medical necessity
This denial is listed twice with the same code. It is also the easiest one to avoid when clinicians understand and appreciate the importance of their documentation. To avoid this denial:
- Read and distribute chapter 7 of the Medicare Beneficiary Coverage Manual. Review specific topics at case conference.
- As much as possible document in the home. Some patients complain that the nurse spends too much time focusing on the computer. To prevent that, as you are finishing up, ask the patient if you can sit and document before you leave. That way, you are not taking your attention away from the patient and if you forgot anything, you are still in the home.
- Display some clinical notes that are truly impressive as examples.
- Turn off the ability to cut and paste if duplicate notes by a nurse are found.
- Read The Z-Factor on the Haydel Consulting Services blog.
- If your job is to review notes, focus on what is important. Medicare does not pay for spelling and grammar and there is little virtue in embarrassing your nurses. Focus on the contents of chapter 7.
Remember that the best reason to document is to communicate the condition of the patient to other clinicians. You don’t have the luxury of shift change report.
5T070 – Visits/Supplies/DME Billed Not Documented/Not Documented As Used
Although this code includes visits, supplies and DME, Palmetto GBA’s explanation of this denial appears to be limited to visits.
The services(s) billed (was/were) not documented in the medical records submitted in response to the Additional Development Request (ADR). As a result, medical necessity for these services could not be determined.
It looks very similar to a denial for medical necessity. Palmetto GBA advises:
To avoid unnecessary denials for this reason, the provider should ensure that adequate documentation is submitted to substantiate the medical necessity for all the services billed when responding to an ADR. The provider may submit discipline visit notes and/or a summary of the services rendered for the billing period. If a summary is submitted, it should include the following: (1) the information for the dates of service billed, (2) documentation of the services that “were rendered” by each discipline billed, (3) documentation of the patient’s condition, and (4) documentation of the patient’s progress/response to the treatments/services rendered.
This information appears to be outdated as visit notes are specified in the list of documentation required for ADRs. Our advice is to:
- Ensure that the recert and therapy evaluation are included if they were performed prior to the starting date of the episode.
- Include lab and other diagnostic tests that substantiate a diagnosis even if is not included in the episode.
5A301 Info Provided Does Not Support the M/N for Therapy Services
The same information that applied to the partial denial for therapy services also applies here so we won’t be redundant and repeat it here.
We hope you don’t need help with appealing denials but we are here for you if you do and to answer any questions about denials you might have received. We would also appreciate any input if you have anything to add, especially about the denial for OASIS and the denial for Visits/Supplies/DME Billed Not Documented/Not Documented As Used. Email us at TheCoders@hhcoding.com.