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

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:

• 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 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

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.

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.

PGBA has indicated as of last week that home health agencies should submit the resume of any RN that will be providing psychiatric services under the home health Medicare benefit to the following address:

Palmetto GBA
Medical Affairs, Part A
Mail Code AG-300
P.O. Box 100238
Columbia, SC 29202-3238

In the April 2010 Medicare Advisory, the RHHI provided the the following list as a recommendation for what to include when responding to a Home Health Additional Development Request (ADR):

Plan of Care and Certification

1. Plan of Care and Certification must be signed and dated prior to billing the end of episode claim.

2. Plan of Care must cover entire billing period.

3. Physician orders not included on the Plan of Care must be signed and dated prior to billing the final claim to Medicare.

4. If alternative signatures are used, submit documentation as outlined in Centers for Medicare & Medicaid Services (CMS) Manual System, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 7, Section 30.2.8.

Documentation of services rendered

1. Adequate documentation is needed to determine medical necessity of all services billed and to support the Health Insurance Prospective Payment System (HIPPS) code (or level of payment) billed.

2. If the medical review for this claim is revenue code specific, you may choose to send notes for the discipline in question, a summary of services rendered or complete field 15 of Form CMS 486 for other disciplines billed; however, all services billed will be reviewed.

3. When intermittency is in question, documentation must include in/out time for nurse and aide visits and the projected endpoint to daily skilled nurse visits. An endpoint statement must include when daily skilled nurse visits are projected to decrease to less than daily.

4. Documentation for all PRN visits, including dates, reason for the PRN visits, outcome of visits and orders for services must be included.

5. Include any other pertinent documentation that may be needed to establish medical necessity (e.g., date of hospitalization, medication changes, laboratory values, physician contacts/visits, etc).

6. Submit documentation denoting treatment week, when different from calendar week.

7. Itemized supply list if billed:

a. Include the quantity and cost of each item.
b. Include physician orders signed and dated prior to billing the end of episode claim to cover all supplies billed.

8. Please send a manifest with medical records submitted and send the medical records in secure packaging to ensure the security of medical records.

9. If responding to multiple requests in a single envelope, ensure each response is clearly separated. If responding to more than one date of service on the same beneficiary, send a response for each request separately. Include a manifest or list identifying each ADR response sent.

10. Attach a copy of the ADR request to each individual claim.

11. Use one staple or elastic band per record to attach the documentation and ADR together. DO NOT use paper clips as they can become dislodged.

12. Do not punch holes in medical records, as this may obscure valuable information.

13. Return the medical records to the appropriate address listed below or on the ADR.

For Postal Delivery Use:
Medicare Part A Medical Review Mail Code: AG-230
P.O. Box 100238
Columbia, Sc 29202-3238

Courier Service, Use:
Medicare Part A Medical Review
Mail Code: AG-230 Building One
2300 Springdale Drive
Camden, South Carolina, 29020-1728

14. Do not include any correspondence other than ADR responses to the medical review department in your envelope.

15. If billing corrections are needed, submit a hardcopy UB-Uniform Billing (latest version from CMS), with a XX7 bill type along with your medical records.

16. Unfortunately, we are not able to accept packages on a C.O.D. basis. Please make sure that you have sent packages with the shipping prepaid.

The Palmetto GBA Medical Review Department developed a Responding to a Home Health Additional Development Request (ADR) checklist. Please complete this checklist and include it when responding to an ADR. This checklist is available on the Palmetto GBA Web site to access this checklist from the Palmetto OBA Web site:

1. Go to www.PalmettoGBA.com/rhhi.

2. Go to the Resources section and select Medical Review

3. Select the Responding to a Responding to a Home Health Additional Development Request (ADR) article.

4. Scroll down to the end of the article and select the PDF document.

According to PGBA, a new inquiry screen has been created in the Direct Data Entry (DDE) system for home health providers which will display the home health payment information that is being accumulated in relation to the 10% cap on outlier payments. Providers may access the information by selecting Option 01 (Inquiries) from the DDE Main Menu and option 67 (Home Health Payment Totals Inquiry) from the submenu. Providers will be required to enter their OSCAR (Provider number) and National Provider Identifier (NPI) to access this information.

The information provided in this article was current as of March 15, 2010. Any changes or new information superseding the information in this article will be provided in articles and publications with publication dates after March 15, 2010 posted at www.PalmettoGBA.com/rhhi.

On March 2, 2010, President Obama signed into law the “Temporary Extension Act of 2010.” Among other things, this law extends through March 31, 2010, the exception process for therapy claims reaching the annual cap, retroactive to January 1, 2010. Affected providers may submit claims for exceptions to the annual therapy caps, with dates of service January 1 through March 31, 2010, using the KX modifier, following the pre-January 1, 2010, requirements for therapy cap exceptions.

PGBA has posted the The Home Health Direct Data Entry (DDE) Handout for you to download or print in PP format. This is an extremely useful resource and a must know for all who are connected to HH billing and appeals.
http://www.palmettogba.com/palmetto/providers.nsf/vMasterDID/82CR6D6188?opendocument