PGBA Medical Review Top Denial COdes No. 9
9. 5FU39/5AU39 – Valid Endpoint Given, But Not Realistic
Reason for Denial
The services billed were not covered because the endpoint statement to daily skilled nursing visits was not realistic.
How to Avoid a Denial
• Ensure that the endpoint to daily visits is realistic based on the beneficiary’s overall condition. Include how you plan to achieve the stated endpoint goal in the documentation.
• Endpoint refers to when the daily skilled nursing visits are expected to be reduced to less than 7 days a week. Medicare will pay for daily skilled nursing visits for a temporary, but not for an indefinite period of time. There may also be circumstances where the patient’s prognosis indicates a medical need for daily skilled services beyond 3 weeks. As soon as the patient’s physician makes this judgment, which usually should be made before the end of the 3-week period, the home health agency must forward medical documentation justifying the need for such additional services and include an estimate of how much longer daily skilled services will be required. A person expected to need more or less full-time skilled nursing care over an extended period of time would not qualify for home health benefits.
• There may be times when an endpoint needs to be adjusted if it becomes evident that the original endpoint is not realistic. Documentation 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.
For more information, refer to:
• Code of Federal Regulations, 42 CFR – Sections 409.34, 409.42 and 409.44.
• CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Chapter 7, Section 40.1.3.
