Good Afternoon to All, Please find below the continuation blogspot as to PGBA's top denial reason codes for home health.
5FT39/5AT39 - No endpoint to daily skilled nursing visits
Reason for Denial
The services billed were not covered because documentation submitted for review did not include an acceptable endpoint statement to daily skilled nursing visits.
OR
The endpoint statement to daily skilled nursing visits was given; however, it was not valid or was unrealistic.
How to Avoid a Denial
• The provider should submit documentation for review that clearly indicates the date skilled nursing visits will be less than daily.
• The endpoint statement should be based on the beneficiary's overall condition.
• Documentation submitted for review should reflect how you plan to achieve the stated endpoint goal. For example, if wound care is the reason for daily skilled nursing visits, documentation should reflect interventions that would promote improvement in the wound to the point of decreasing the frequency of visits. Some of these interventions may include, but are not limited to, the following:
o Correspondence with the physician
o Changes in treatments and/or medications
o Medical social worker involvement
o Dietician consultation regarding nutritional/hydration needs o Evaluation of supply or durable medical equipment needs
o Other interventions
• There may be times when an endpoint needs to be adjusted if it becomes evident that the original endpoint is not realistic Documentation submitted for review must support the revised endpoint as realistic and what precipitated the change in medical condition.
• Continual extensions of endpoint for daily skilled nursing visits may be viewed as not finite and predictable.
• The Medicare Home Health Benefit was not established to provide daily skilled nursing services, but rather, to provide intermittent skilled nursing services.
For further information, refer to:
• Code of Federal Regulations, 42 CFR - Sections 40934,409.42 and 409.44
• CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Chapter 7, Section 40.1.3
Monday, May 24, 2010
Tuesday, May 18, 2010
Continuation Blog of PGBA's Top Denial Reason Codes
Pleae find below the most recent posting on PGBA's top denial reason codes
6. 5T099 -Billing Error
Reason for Denial
The service(s) billed (was/were) not covered because, according to the documentation in the medical record, the home health agency made a billing error. Therefore, no Medicare payment was made. The home health agency may not charge the beneficiary for service(s) that (was/were) billed in error.
How to Avoid a Denial
• Check all charges for accuracy/timeliness prior to submitting the final bill to Medicare.
• Check to ensure that all documentation submitted in response to the ADR corresponds to the service(s) rendered and the dates of service(s) billed.
For more information, refer to:
• CMS Manual System, Pub 100-04, Medicare Claims Processing Manual, Chapter 10, Sections 10.1.11 and 10.1.23
• CMS Manual System, Pub 100-04, Medicare Claims Processing Manual, Chapter 1, Section 60.1.1
6. 5T099 -Billing Error
Reason for Denial
The service(s) billed (was/were) not covered because, according to the documentation in the medical record, the home health agency made a billing error. Therefore, no Medicare payment was made. The home health agency may not charge the beneficiary for service(s) that (was/were) billed in error.
How to Avoid a Denial
• Check all charges for accuracy/timeliness prior to submitting the final bill to Medicare.
• Check to ensure that all documentation submitted in response to the ADR corresponds to the service(s) rendered and the dates of service(s) billed.
For more information, refer to:
• CMS Manual System, Pub 100-04, Medicare Claims Processing Manual, Chapter 10, Sections 10.1.11 and 10.1.23
• CMS Manual System, Pub 100-04, Medicare Claims Processing Manual, Chapter 1, Section 60.1.1
Monday, May 10, 2010
Additional Outlier Payment Guidance - PGBA
CMS Pub 100-04, Medicare Claims Processing Manual, Chapter 10, Home Health Agency Billing (10.1.21 Adjustments of Episode Payment - Outlier Payments)
Effective January 1, 2010, for calendar year 2010, the outlier payments made to each home health agency (HHA) will be subject to an annual limitation. Medicare systems will ensure that outlier payments comprise no more than 10 percent of the HHAs total HH PPS payments for the year. Medicare systems will track both the total amount of HH PPS payments that each HHA has received and the total amount of outlier payments that each HHA has received. When each HH PPS claim is processed, Medicare systems will compare these two amounts and determine whether the 10 percent has currently been met.
If the limitation has not yet been met, any outlier amount will paid normally. (Partial outlier payments will not be made. Only if the entire outlier payment on the claim does not result in the limitation being met, will outlier payments be made for a particular claim.) If the limitation has been met or would be exceeded by the outlier amount calculated for the current claim, other HH PPS amounts for the episode will be paid but any outlier amount will not be paid. When the calculated outlier amount is not paid, HHAs will be alerted to this by the presence of claim adjustment reason code 45 on the accompanying remittance advice. This code is defined "Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement."
Effective January 1, 2010, for calendar year 2010, the outlier payments made to each home health agency (HHA) will be subject to an annual limitation. Medicare systems will ensure that outlier payments comprise no more than 10 percent of the HHAs total HH PPS payments for the year. Medicare systems will track both the total amount of HH PPS payments that each HHA has received and the total amount of outlier payments that each HHA has received. When each HH PPS claim is processed, Medicare systems will compare these two amounts and determine whether the 10 percent has currently been met.
If the limitation has not yet been met, any outlier amount will paid normally. (Partial outlier payments will not be made. Only if the entire outlier payment on the claim does not result in the limitation being met, will outlier payments be made for a particular claim.) If the limitation has been met or would be exceeded by the outlier amount calculated for the current claim, other HH PPS amounts for the episode will be paid but any outlier amount will not be paid. When the calculated outlier amount is not paid, HHAs will be alerted to this by the presence of claim adjustment reason code 45 on the accompanying remittance advice. This code is defined "Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement."
Wednesday, May 5, 2010
PGBA RHHI Part A Medical Review Top Denial Reason Codes
This is 4th posting in a series of top Home Health denial reasons as published by PGBA. A reference section has been added at the end of each denial code by PGBA to provide an additional resource for information on how to avoid these denials. Please note these references are not all inclusive.
4. 5F071/5TO71- Orders Do Not Cover All Visits Billed
Reason for Denial
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.
How to Avoid a 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.
• 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.
For more information, refer to:• Code of Federal Regulations, 42 CFR - Sections 409.43 and 484.18
• CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Chapter 7, Sections 30.2.1, 30.2.2 and 30.2.5
4. 5F071/5TO71- Orders Do Not Cover All Visits Billed
Reason for Denial
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.
How to Avoid a 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.
• 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.
For more information, refer to:• Code of Federal Regulations, 42 CFR - Sections 409.43 and 484.18
• CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Chapter 7, Sections 30.2.1, 30.2.2 and 30.2.5
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