Home Health & Hospice Week

COPD claims also see high denial rate.

If you're submitting claims for long-stay patients with chronic diseases, you'd better work on your documentation for them. That's because two edits at regional home health intermediary Cahaba GBA that focus on COPD and hypertension patients have seen sky-high denial rates.

Edit No. 1, 5THBX, reviews claims with a length of stay greater than 120 days and primary diagnosis of 496.xx, indicating COPD. The denial rate for the edit is a whopping 85 percent, Cahaba says in its September newsletter for providers.

Edit No. 2, 5023T, targets claims with a length of stay greater than 120 days, a primary diagnosis of 401.9 indicating hypertension, and five to nine nursing visits. The edit's denial rate is an even higher 98 percent.

The chief reason for denials for both edits is "5HMED: Documentation does not support medical necessity of services billed," Cahaba notes.

"Although the topics of the edits are driven by a diagnosis, the denials were not due to 'coding,'" Cahaba tells providers. "The entire medical record is reviewed, and for both edits, the overwhelming top denial was related to documentation of medical necessity of the skilled services."

Agencies' main problem was failure to document to support 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," Cahaba says. "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."

Resource: More information about the edits is in this month's Newsline at http://www.cahabagba.com/rhhi/news/newsletter/201009_rhhi.pdf.