Home Health & Hospice Week

Tip: Documentation must include physician’s actual visit note.

If you want your claims to pass review under the second round of Probe & Educate review, make sure your documentation practices avoid the most common Face-To-Face physician encounter pitfalls.

MACs CGS and Palmetto GBA revealed to Eli that their denial rates for Probe & Educate Round 1 were a hair under and over the 60 percent mark, respectively (see Eli’s HCW, Vol. XXVI, No. 3).

In an article posted Jan. 10, HHH Medicare Administrative Contractor CGS says F2F problems “accounted for approximately 2,911 (63 percent) of the total Probe and Educate denials.” Common problems the MAC cites are:

• Actual F2F encounter document not submitted

• Certifying physician did not document the date of the F2F encounter

• Community physician was not identified when a physician who would not be following the patient after discharge signed the certification

• Estimated length of skilled services was not documented in the recertification document

• Required elements for initial certification (initial plan of care, initial certification, initial encounter documentation) were not submitted for recertification.

These Denial Reasons Lead The Pack

CGS shared details on the other top denial reasons with Eli as well.

Reason #1: “Certification issues,” including:

• F2F missing/incomplete/invalid/untimely — 46 percent.

• Recertification estimate missing — 12 percent (for more details about this requirement, see Eli’s HCW, Vol. XXIV, No. 25).

• Initial cert missing/invalid — 5 percent.

Reason #2: No response to Additional Development Request (ADR) — 23 percent. “Documentation must be received by CGS within 45 calendar days,” the MAC reminds on its website. “Claims will be denied if the documentation is not received by day 46.” (For tips on combatting ADR non-responses, see Eli’s HCW, Vol. XXV, No. 12.)

Reason #3: Medical necessity of therapy services — 13 percent.

Note: See the CGS article at http://cgsmedicare.com/hhh/pubs/news/2017/0117/cope1772.html.