PGBA Home Health Medical Review Top Denial Reason Codes

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.


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

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