Good Morning All, This is the 10th and final posting of the top PGBA Home Health denial reasons. I hope you all garnered some vlauable insight from these postings. See you all again next week.
10. 5F01215T012 — Physician’s Plan of Care and/or Certification Present – Signed but Not Dated
Reason for Denial
The services billed were not covered because the physician signed but did not date the plan of care and certification prior to billing Medicare.
How to Avoid a Denial
• In order to avoid unnecessary denials for this reason, the provider should verify that the physician has dated his or her signature. If the physician does not date his or her signature on the plan of care (Form CMS-485) in field 27, the provider may write or stamp in field 25, the date on which the signed plan of care was received from the physician. If the stamp date is not in field number 25 of the plan of care, the stamp date must indicate “Received” with the date. The stamp date should be in black ink, as red or blue ink does not photocopy. The physician must certify that:
• The home health services were required because the individual was confined to his or her home and needs intermittent skilled nursing care, physical therapy and/or speech-language pathology, or continues to need occupational therapy.
• A plan for furnishing such services to the individual has been established and is periodically reviewed by a physician; and the services were furnished while the individual was under the care of a physician.
• Since the certification is closely associated with the plan of care, the same physician who establishes the plan must also certify to the necessity for home health services. Certifications must be obtained at the time the plan of care is established or as soon thereafter as possible.
• There is no requirement that a specific form must be used, as long as the intermediary can determine that this requirement is met. When requesting reimbursement for a claim, the provider must have the certification on file and be able to submit this information if medical records are requested by the intermediary.
• The physician must recertify at intervals of at least once every 60 days that there is a continuing need for services and should estimate how long services will be needed. The recertification should be obtained at the time the plan of care is reviewed and must be signed by the same physician who signs the plan of care. When requesting reimbursement for a claim, the provider must have the recertification on file and be able to submit this information if medical records are requested by the intermediary_
For more information, refer to:
• Code of Federal Regulations, 42 CFR – Sections 409.41, 409.42,409.43 and 424.22.
CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Chapter 7, Section 30.2 and 30.5.
• CMS Manual System, Pub 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4, Section 30.
