Home Health & Hospice Week

Therapy once again tops the reasons for denials in Palmetto GBA’s latest medical review effort.

The HHH Medicare Administrative Contractor recounts denying 9 of 98 1CHP* claims reviewed in New Mexico. 1CHP indicates claims with the highest Clinical, Functional, and Service Domain scores. The review covered claims processed between November 2016 and May 2017.

However: “The total dollars reviewed was $368,430.12 of which $18,292.05 was denied, resulting in a charge denial rate of 4.96 percent,” Palmetto says on its website.

The top denial reason dollars-wise was “5F301/5A301: Information Provided Does Not Support the Medical Necessity for Therapy,” Palmetto says. And “5CHG3: Medical Review HIPPS Code Change Due to Partial Denial of Therapy” was the second-most common denial reason, the MAC says on its website.

These therapy-based denials also topped the list in Palmetto’s recent wide-ranging review of nearly 12,000 claims (see Eli’s HCW, Vol. XXVI, Nos. 20-22).

Plus: The third-most common denial reason was “5FNOA/5ANOA: No Initial OASIS/OASIS Present for SCIC HIPPS Code.” Palmetto stresses on its website that “appropriate payment for the entire episode cannot be determined without the OASIS for the initial HIPPS code. As a result, all of the services billed are non-covered.”