Home Health & Hospice Week

Lack of documentation for OASIS M0 items edged out face-to-face as the chief reason for denials in Palmetto GBA’s latest medical review of high-therapy claims.

Palmetto reviewed claims with a HIPPS code of 5BHK*, processed Feb. 1 to April 15. 5BHK* are claims with the highest (20-plus visits) therapy category, mid-clinical score (2) and highest functional score (3). It has a 2014 case-mix weight of 2.0230 — the fifth-highest possible.

Of the 309 claims Palmetto reviewed in Florida, Texas, Illinois, Louisiana, and Mississippi, 84 had denials at least partly due to “Medical Re-view HIPPS Code Change/Documentation Contra-dicts M0 Item(s),” Palmetto says on its website. That compares to 73 claims that had F2F problems, according to the edit results.

However, the dollar impact of the two types of denials will differ, since entire claims are denied due to F2F while the M0 item reason generally carries downcodes.

For a list of states affected and stats broken out by region, see the articles at www.palmettogba.com/medicare — click on “J11 MAC – Home Health and Hospice” in the left column, then click on “Medical Review” in the left column and choose the “Results” tab below it. Choose the 5BHK results articles in the right column.