Tag / Medicare Denials

by Julianne Haydel

Home Health Denials


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:

  1. Use Option 12
  2. Enter your NPI number and status/location of ‘S B60001’
  3. ADRs will appear as reason code 39700
  4. 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:

  1. Uploading the documents when you are able.
  2. Mail the documents with proof of delivery requested.
  3. Track delivery.
  4. 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.
  5. 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.
  6. 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:

  1. 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.
  2.  The physician clinic visit or hospital documentation will be used to establish eligibility.
  3. 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.
  4. 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:

  1. The plan of care was not signed.
  2. The plan of care was signed by a Nurse Practitioner or Physician Assistant
  3. A different physician than the one listed on the plan of care signed it.
  4. The signature was not dated although there is a seperate code for this.
  5. 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:

  1. Document not only how far the patient ambulated but how they tolerated the ambulation.
  2. Take pre and post vital signs.  Document balance and gait disturbances.
  3. Always document pain and discomfort in quantitative measures.
  4. Document any complaints or new orders not related to therapy and report them to the case manager.  Follow up in writing.
  5. 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:

  1. If possible (and it should be possible), include therapy frequency on the plan of care.
  2. Consider amending your standard therapy contract to state that the agency will not pay for unauthorized visits.
  3. 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.
  4. 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.
  5. The same signature and dating rules apply to MD signatures on interim orders.
  6. The correct way to write an order that was received earlier is:
    1. Date the document on the day it was written
    2. Begin the order with, ‘Effective on (the date you received the order)
    3. 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:

  1. Read and distribute chapter 7 of the Medicare Beneficiary Coverage Manual.  Review specific topics at case conference.
  2. 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.
  3. Display some clinical notes that are truly impressive as examples.
  4. Turn off the ability to cut and paste if duplicate notes by a nurse are found.
  5. Read The Z-Factor on the Haydel Consulting Services blog.
  6. 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:

  1. Ensure that the recert and therapy evaluation are included if they were performed prior to the starting date of the episode.
  2. 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.

by Julianne Haydel

Hospice Coding


coding wordle 2

 

72 percent of hospice claims list only one diagnosis.  The diagnosis used most often is Debility. The third most frequently used diagnosis is adult failure to thrive. 

That means that upwards of 75 percent of hospices may have some real problems soon.  The requirement that hospices adhere to the ICD-9 coding guidelines is not new.  It is written into the original 1983 hospice guidelines and CMS is very much aware that hospices are not following the long established rules of coding.

Hospices have responded by building cheat sheets and lists of common hospice diagnoses.  It’s a great idea but it probably won’t work.  It didn’t work for hospitals in the 90’s or home health agencies after their prospective payment system was refined in 2008.  To this day agencies that depend on untrained nurses to code are losing money by insufficient coding or worse, getting denied because of invalid codes.

The biggest mistake that home health agencies made all those years ago after PPS was implemented was not taking coding seriously.  With four exceptions, the ICD-9 coding performed by an agency did not affect payment.  As such, diagnosis coding was not taken very seriously by home health. 

That turned out to be a mistake. Diagnoses that required significant resources to treat were not included in future updates to the payment system.  Incorrect, poorly specified diagnoses were included but when coded correctly, they did not add to the reimbursement.

I am not going to pretend that I am psychic and charge you for my insight into the future.  I can only say that I see this happening to the Hospice Industry in the not-so-distant future.

How could this stubborn insistence on following the rules be any worse, you ask?  It comes right as the rest of the world is transitioning into ICD-10 coding.  That’s right.  By the time you get the hang of ICD-9 Coding, the rules of the game will change.

It’s almost as though Medicare has taken up our cause as their own and has begun emphasizing the value of our coding services.  Thank you, Medicare for the plug.  Can we talk about the face-to-face requirement, now?

If you do not want to outsource coding, there are other options (but none as good as contracting with us or another reputable company).

  1. If your hospice has common ownership with a home health agency, remember that this is not new to them.  Make some kind of arrangement with them. 
  2. When you are recruiting nurses or billers, put coding on the top of the list of preferred skills.
  3. Go online and look for certified coders.  Remember, coders do not have to be nurses.
  4. If there is a school that offers RHIT certification in your area, offer a student internship.  You might end up with the employee of a lifetime or a dud.  It is worth the gamble because they are trained in coding, electronic health information, etc.   
  5. Outsource ICD-9 coding and focus on investing in ICD-10 coding preparation for your staff. 

Remember, people do not wake up one morning and try as hard as they can to thrive and fail.  If you cannot come up with a good underlying reason, expect denials.  Not being paid fairly could easily be the result of poor coding which might lead to a poor outcome for hospices that go the extra mile to ensure patients and their families are comfortable at the end of life.  It takes resources to provide the kind of care that matters.  Don’t cheat your hospice or your patients by failing to take this seriously.

As always, Delaine and Jackie can be reached via email or you can call 337-654-7934. 

by Julianne Haydel

Face to Face Answers


If you have not already taken the quiz on Face to Face encounter for home health, please do so by clicking here before continuing.  The answers are as follows.

When should the face to face encounter occur?

The face to face encounter should always occur within the 90 days prior to admission for home health services or within 30 days following the admission.  However, if a physician visit in the prior 90 days was not for reasons related to home health services, an additional visit is required related to home health services.

Who may sign the face to face encounter? 

The physician who orders home health services must always sign the face to face encounter. 

How can you  best assist the physician in the face to face process?

The best way to assist the physician is with education.  Not only do physicians resent the additional paperwork but if your agency is following the guidelines, there is a really good chance that you are competing against other agencies that complete the face to face documentation for the physician.  By educating your referral sources, you are also protecting them from inadvertently participating in fraudulent activity. 

A physician documents that a patient is confined to the home because they do not drive.  What should you do?

The correct answer is to visit with the physician and ask him to document why the patient does not drive. Assuming the reason that the patient does not drive is related to their health and not lost keys, the physician will hopefully understand homebound status a little better after your discussion.

Which of the following is not true about Face to Face Documentation?

Although it seems redundant as it is repeated so many times, a common reason for face to face denials is that the physician who certified the plan of care did not sign the face to face document. 

Which of the following is not true about Face to Face Documentation?

Yes, there are two questions that read the same.  This refers to question 8 and the only untrue answer is that the face to face should not be sent by the hospitalist while the referring physician sends the certification.  The face to face document is considered a part of the initial certification.

Everything else is true.  The physician may use drop down boxes in his or her software if they adequately describe the patient.  The entire face to face document may be computer generated and recent denials because the date of the encounter was not handwritten are erroneous on the part of the MAC. That is not a requirement.

Which is true regarding the physician narrative?

The correct answer is that it should contain the patient’s condition at the time of the encounter.  When the face to face documentation differs from the agency documentation, a denial may result.  For instance, a physician states the patient needs therapy and upon admission, the patient refuses therapy.  Because the patient is new anticoagulation therapy, the patient is admitted from services.  This type of discrepancy has resulted in numerous denials.

When is it acceptable to bill without a face to face encounter?

The only time it would be considered acceptable to bill without a face to face encounter would be if the patient dies prior to the 30th day and the agency can show that efforts were in progress for the patient to see the physician.  Please note we are not suggesting that you introduce your patient to the great hereafter if the patient does not go to the physician as planned.

When the referring physician is unavailable, the Medical Director may sign the Certification and Face to Face documentation.  (T/F)

False.  The only time the Medical Director may sign the face to face documentation is on those occasions when the patient was seen and referred by the Medical Director.  These referrals must fall under the confines of Stark and Anti-kickback laws that prohibit the sale of patients.

The face to face documentation is required on all patients admitted to a Medicare certified agency regardless of payor source.  (T/F)

This is actually a trick question because Medicare clearly states that only Medicare patients require a face to face document.  Try telling Humana that.  They are denying claims based on the language in their contracts with agencies that all Medicare rules apply to Humana patients as well.  Get one on everyone just to be safe.

The physician who signs the plan of care must also sign the face to face encounter. (T/F)

If you started this Face to Face adventure believing anything else and you now know better, you have not wasted your time. 

What is true about face to face documents prepared by a hospital physician who then handed off the patient to a community physician?

A final, often overlooked reason for denial is that any document that is used as the face to face document must be clearly labeled as the face to face document.  If the physician merely staples a discharge summary with all the pertinent parts on it to the plan of care, it will not suffice.  ALF’s often have a form that contains al of this information but if it is not labeled as a face to face, it will not count.  Finally, some hospitals have software that generate a document that looks like a face to face without being labeled.  This is an easy fix and I trust you will never be denied for an unlabeled face to face in the future.

How did you do?  Did you learn anything?  Feedback is always welcome and criticism is swallowed whole when offered with our best interests in mind.

The Coders want  you to get paid.  Together with our affiliated companies, HCMB billing and Haydel Consulting Services LLC, we are prepared to offer billing, coding and clinical consulting services tailored specifically to your needs.  Contact us today by email or click here to get your questions answered.  And be sure to subscribe to our blog so you won’t a single post.