Home Health & Hospice Week

In its latest medical review results for high-therapy claims, Palmetto GBA makes a big chunk of denials for face-to-face reasons — but it’s not quite as big a chunk as in some previous reviews.

 

Stats: For HIPPS codes 5BHK* and 5CHK*, which include the highest therapy and functional scores, the HHH Medicare Administrative Contract-or denied 108 of the 489 claims reviewed — 22 percent. Within those denials, face-to-face reasons caused the full or partial denial 57 percent of the time, Palmetto’s results show.

 

The 57 percent figure compares to stats ranging up to 100 percent of denials in recent reviews, and the 22 percent overall denial rate compares to 100 percent in some recent reviews too (see Eli’s HCW, Vol. XXII, No. 38, Vol. XXIII, No. 9).

 

More review: Both codes 5BHK* and 5CHK* have been identified as “a major risk” in Palmetto’s area, the MAC says on its website. The edit effectiveness results “indicate high impact severity errors,” so the service-specific probes will progress to targeted medical review in certain states. “If significant billing aberrancies are identified, provider-specific medical review may be initiated,” Palmetto warns.

 

Resource: 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 April 18 results articles in the right column.