PGBA RHHI Part A Medical Review Top Denial Reason Codes

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:

• Code of Federal Regulations, 42 CFR – Sections 409.32, 409.33 and 409.44

• CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual,, Chapter 7, Sections, and

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