Home Health & Hospice Week

Therapy visit medical necessity comes in second.

Know what denials your claims may be most vulnerable to by perusing the top five denial reasons under the first six months of the Targeted Probe & Educate medical review program.

HHH Medicare Administrative Contractor CGS lists the five most common denial reasons in a new article reporting its TPE results from Oct. 1, 2017, to March 31, 2018:

1. Face-to-Face missing/incomplete/untimely (30 percent of CGS's TPE Round 1 denials). Problems included that the actual F2F encounter document was not submitted; the certifying physician did not document the date of the F2F encounter; the community physician was not identified when a physician who would not be following the patient after discharge signed the certification; and the required elements for initial certification (initial plan of care, initial certification, initial encounter documentation) were not submitted for recertification.

2. Therapy visits not medically necessary (18 percent). Documentation did not support medical necessity of therapy services.

3. Initial certification invalid (6 percent).

4. Skilled nursing not medically necessary (6 percent).

5. Plan of care missing/invalid (5 percent).

Plus: CGS doesn't include non-response to the Additional Development Request in its top five denial reason list. However, the MAC notes that two of the 12 providers (out of 15) that it found "non compliant" in TPE Round 1 didn't respond to ADRs.