Home Health & Hospice Week

If you're submitting claims for five-visit episodes with a single nurse or social worker visit, you're at high risk of denials. Regional home health intermediary Cahaba GBA is continuing to run widespread edits on these two types of claims, it says in its March newsletter for providers. And both types of claims are turning up high denials rates -- 83 percent for the claims with one nurse and four therapy visits, 75 percent for the claims with one medical social worker and four other visits.

For the single nurse visit edit, "the top denial reason ... was related to medical necessity of the one-time skilled nurse visit," Cahaba explains. If the nurse opens the case and performs the start of care assessment, that visit is not billable -- unless the nurse also delivers a medically necessary skilled nursing service.

Tip: "If the skilled need for the nurse is observation and assessment, there is greater need than a one-time visit," Cahaba says. And don't forget that the therapist can perform a SOC assessment.

For the single MSW visit, "many of these denials are related to the medical necessity of nursing and/or the MSW visit," Cahaba reports. "Routine evaluations for community resources where no needs were previously identified would not be considered a covered MSW service."

More information is in the Newsline at www.cahabagba.com/rhhi/news/newsletter/201103_rhhi.pdf.