Home Health & Hospice Week

Make sure your claims with hypertension codes can withstand medical review, or you’ll pay the price.

In the latest quarter, HHH Medicare Admin-istrative Contractor CGS racked up an 85 percent denial rate under an edit that selects claims for pre-pay review based on "hypertension diagnoses and length of stay greater than two episodes of care," the MAC reveals in its December newsletter for providers. "This is down from the 95 percent denial rate a year ago but remains high," CGS notes.

The top reason for denials was lack of medical necessity, CGS notes. Many of those denials were based on nursing visits for observation and assessment. "For a skilled service of observation and assessment to be covered by Medicare, there must be clear documentation of the patient’s condition that warrants this service," the MAC stresses. "Typically, documentation of changes in diagnosis, exacerbations, medication or treatment changes that continue to put the beneficiary at risk for further plan of care changes shows the medical necessity for observation and assessment."

Remember: The Medicare Benefit Policy Manual tells providers that "observation and assessment by a nurse is not reasonable and necessary to the treatment of the illness or injury where these indications are part of a longstanding pattern of the patient’s condition which itself does not require skilled services and there is no attempt to change the treatment to resolve them,’" CGS says.

CGS’s newsletter is at http://cgsmedicare.com/hhh/pubs/mb_hhh/2013/12_2013/index.html.