PGBA RHHI Part A Medical Review Top Denial Reason Codes

This is 4th posting in a series of top Home Health denial reasons as published by PGBA. A reference section has been added at the end of each denial code by PGBA to provide an additional resource for information on how to avoid these denials. Please note these references are not all inclusive.

4. 5F071/5TO71- Orders Do Not Cover All Visits Billed

Reason for Denial

The submitted physician’s orders for services did not cover all of the visits billed. An example of this is when physician’s orders were submitted for seven physical therapy visits; however, 10 were billed.

How to Avoid a Denial

In order to avoid unnecessary denials for this reason code, ensure that the physician’s orders (1) include a legible physician signature dated prior to billing Medicare, and (2) cover the services to be billed. The Medicare program requires that the physician order all services and that a plan of care is set up for furnishing services. When responding to an ADR, do the following:

• Ensure that all orders for services billed are included with the medical records.
• If orders do not cover the visits billed or visits need to be added, submit a corrected, hardcopy UB-04 with a 337 or 327 bill type with the medical records.

For more information, refer to:• Code of Federal Regulations, 42 CFR – Sections 409.43 and 484.18

• CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Chapter 7, Sections 30.2.1, 30.2.2 and 30.2.5

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