Home Health & Hospice Week

More than 70% of denied claims due to F2F in recent probe.

Whether Medicare will make elimination of the physician narrative for face-to-face retroactive is a vital issue for many home health agencies, including those with claims reviewed in a recent therapy-focused probe.

HHH Medicare Administrative Contractor Palmetto GBA announced the latest results from its probes targeting claims with HIPPS codes of 1BGP*, 5BHK*, and 5CHK*. Of the 1,773 claims with these HIPPS codes that it reviewed from the May-to-July time period, Palmetto partially or fully denied 708 — 40 percent.

Background: 1BGP* indicates 11 to 13 therapy visits, a mid-clinical score (2) and mid-functional score (2). 5BHK* indicates 20-plus therapy visits, a mid-clinical score (2) and the highest functional score (3). 5CHK* indicates 20-plus therapy visits, the highest clinical score (3) and highest functional score (3).

F2F continues to be a dominant denial reason in the 1BGP* probe. Twenty-eight percent of the 1,703 claims reviewed were denied due to F2F. That makes F2F the reason for 71 percent of the probe’s denials.

Palmetto says it will continue all three probes in most of the areas for another quarter.

Medical necessity was another significant reason for denials, the results show. Failure to respond to the additional development request with records, missing OASIS data, documentation contradicting OASIS M items, and missing plans of care or other physician documentation were more reasons Palmetto cited for denials.

Pitfall: Missing dates for physician signatures accounted for 10 percent of the reimbursement denied in the 5CHK results for Texas.