5F031/5A031 – Skilled Observation Not Needed from Start of Care
Reason for Denial
The claim was fully or partially denied because the clinical documentation submitted for review did not support the medical necessity of the skilled services from start of care.
How to Avoid a Denial
PGBA recommends the following in avaoiding this type of denial:
• Submit all documentation related to the services rendered and billed to Medicare which supports the medical necessity of the services. The documentation should support a reasonable potential of a complication or further acute episode in the patient’s condition. The key to Medicare coverage is for the documentation to “paint a picture” of the beneficiary’s overall medical condition indicating the need for skilled services.
• Ensure a legible signature is present on all documentation necessary to support orders and medical necessity.
• Submit all documentation that would support medical necessity for services. Some examples for services may include, but are not limited to, the following:
1. New and/or changed prescription medications.
2. “New” medications are those that the patient has not taken recently, i.e. within the last 30 days.
3. “Changed” medications are those that have a change in dosage, frequency or route of administration within the last 60 days.
4. New onset or acute exacerbation of diagnosis.
5. Hospitalizations (include the date and reason.)
6. Acute change in condition.
7. Changes in treatment plan as a result of changes in condition (i.e. physician’s contact, medication changes.)
8. Changes in caregiver status.
9. Complicating factors (i.e. simple wound care on lower extremity for a patient with diabetes.)
10. Inherent complexity of services that causes them to be safely and effectively provided only by skilled professionals
For more information, PGBA recommends you refer to:
• Code of Federal Regulations, Sections 409.32, 409.33 and 409.44
• CMS Internet-only Manuals (lOMs), Pub 100-02, Medicare Benefit Policy Manual, Chapter 7, Section 40.1.2.1
• CMS Internet-only Manuals (lOMs), Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.4.1.1.
