PGBA RHHI Part A Medical Review Top Denial Reason Codes

This is a continuation from last week's posting of Reason No. 2.

This is Reason No. 3

PGBA recently posted this to their website and encourages all providers to review this information when filing claims to prevent denials and to ensure their claims are processed timely. A reference section has been added at the end of each denial code to provide an additional resource for information on how to avoid these denials. Please note these references are not all inclusive.

3. 5F041/5A041 – Information Provided Does Not Support the Medical Necessity for All or Part of This Service

Reason for Denial
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.

How to Avoid a Denial

• Submit all documentation related to the services rendered and billed to Medicare which supports the medical necessity of the services.

• 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 (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 (i.e., 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 1M/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:

o Is the patient at HIGH RISK for hospitalization or exacerbation of a health problem if the plan of care is not implemented properly (i.e., multiple medical problems Or diagnosis, limitations in activities of daily living or mental status, cultural barriers, history of repeated hospitalizations)?

o Does the patient have a COMPLEX, UNSKILLED care plan (i.e. many medications, treatments, use of complex or multiple pieces of equipment, unusual variety of supplies)?

o Is there an UNSTABLE CAREGIV1NG situation (i.e. involvement of many services or community resources, unsafe or unclean environment that interferes with putting the plan into action)?

o Does it require the skills of a registered nurse or a qualified therapist to ensure safe and appropriate implementation of the plan of care?

For more information, refer to:

• Code of Federal Regulations, 42 CFR - Sections 409.32, 409.33 and 409.44

• CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual,, Chapter 7, Sections 40.1.2.1, 40.1.2.2 and 40.1.2.3

PGBA Home Health Medical Review Top Denial Reason Codes

PGBA recently posted this information when filing claims to prevent denials and to ensure your HHA claims are processed timely. A reference section has been added at the end of each denial code to provide an additional resource for information on how to avoid these denials. Please note these references are not all inclusive.

1. 56900 - Lack of Response to Medical Record Request (Refer to Section 1— Denial Reason Code 56900)
Section 1- Denial Reason Code 56900
The denial reason 56900, lack of response to Additional Development Requests (ADRs), has been reported as one of the top denial reasons for most of these benefit types. Since 56900 is common to most benefit types, we have listed this denial code separately to encourage providers to follow the instructions in the How to Avoid a Denial section before submitting claims to Palmetto GBA. Following these instructions should decrease delays in processing your claims.

Reason for DenialMedical records were not received in response to an ADR in the required time frame; therefore, we were unable to determine medical necessity.

How to Avoid a 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.

• Alert your mail staff that the ADRs will be mailed by Palmetto GBA in bright yellow envelopes with "ADR REQUESTS TIME SENSITIVE" stamped in red on the outside of the envelope to assist them in readily identifying the ADRs.

• 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. Ensue 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.




2. 5CHG1 - Medical Review HIPPS Code Change/Documentation Contradicts M0 Item(s)
Reason for Denial

The services billed were paid at a different payment level. Based on medical review, the original HIPPS code was changed.

How to Avoid a Denial
To avoid changes for this reason, the documentation should paint a consistent picture of the patient's condition.

For more information, refer to:
• Outcome and Assessment Information Set Implementation Manual www.cms.hhsgov/oasis/

• American Health information Management Association (Web based training course available) - www.ahlma.org

• Centers for Disease Control and Prevention lCD and ICF Home Page www.cdc.gov/nchs/icd.htm

October, November and December 2009 RHHI Medical Review Top Denial Reason Codes

Medicare's Home Health Intermediary PGBA encourages all providers to review the information below when filing claims to prevent denials and to ensure their claims are processed timely. A reference section has been added by PGBA at the end of each denial code to provide an additional resource for information on how to avoid these denials. Please note these references are not all inclusive by PGBA.

Med Form Store will be posting 10 weekly PGBA denial code prevention updates. Enjoy the first posting below.

Denial Reason #1: Code 56900

The denial reason 56900, lack of response to Additional Development Requests (ADRs), has been reported as one of the top denial reasons for most of these benefit types. Since 56900 is common to most benefit types, we have listed this denial code separately to encourage providers to follow the instructions in the How to Avoid a Denial section before submitting claims to Palmetto GBA. Following these instructions should decrease delays in processing your claims.

Reason for Denial

Medical records were not received in response to an ADR in the required time frame; therefore, we were unable to determine medical necessity.

How to Avoid a 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.

• Alert your mail staff that the ADRs will be mailed by Palmetto GBA in bright yellow envelopes with "ADR REQUESTS TIME SENSITIVE" stamped in red on the outside of the envelope to assist them in readily identifying the ADRs.

• 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. Ensue 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.

Medicare Home Health Rural Add-on

Pursuant to a recent CMS posting, on March 23, 2010, President Obama signed into law the Patient Protection and Affordable Care Act (PPACA), which creates a 3% add-on to payments made for home health services to patients in rural areas. The add-on applies to episodes ending on or after April 1, 2010, through December 31, 2016. Similar to temporary rural add-on provisions in the past, claims that report a rural state code (code beginning with 999) as the Core Based Statistical Area (CBSA) code for the beneficiary’s residence will receive the additional 3% payment. The CBSA code is reported associated with value code 61 on home health claims.

The Centers for Medicare & Medicaid Services is working to expeditiously implement the home health rural add-on provision, Section 3131(c), of the PPACA.