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Home Health & Hospice Week

Medical Review:

DON'T LET THIS TOP DENIAL REASON DOOM YOUR REIMBURSEMENT

Published on Thu Apr 28, 2005

Physician orders are the cornerstone of a solid billing program.

Four of the top ten denial reasons listed recently by regional home health intermediary Palmetto GBA have to do with physician orders:
 
  • 5F011: The plan of care and certification were present, however, the claim was fully denied because the POC and cert were not signed by the physician prior to billing Medicare; or if a Form CMS-485 was used, the signature or "received" date stamped in field 25 of the POC and cert was after the date the claim was billed.
     
  • 5T072: The claim has some or all services denied due to insufficient physician orders or the order was not obtained prior to the service being rendered.
     
  • 5T073: The claim has some of the services denied as the physician orders were not signed and/or dated prior to billing the claim.
     
  • 5T078: The claim has some or all of the services denied due to incomplete physician orders.

    If you are seeing denial code 5F011 crop up frequently, the problem is that you're not getting the POC and cert signed and dated correctly, explains consultant Rose Kimball with Dallas-based billing company Med-Care Administrative Services.

    Denial codes 5T072 and 5T078 point to a problem with the orders being too vague and lacking necessary detail, Kimball says. Another reason for the denials could be that you neglected to include the applicable orders when you submitted the documentation in response to the Additional Development Request (ADR), Palmetto notes.

    $2,000 Mistake: Denial code 5T073 has been a big money-loser for home health agencies, because it often focuses on orders for therapy, Kimball notes. In a common scenario, physicians will order a physical therapy evaluation of the patient at the outset of the episode, but then the HHA fails to secure signed and dated physician orders for the subsequent therapy visits the PT designates. That bumps a patient from a therapy to a non-therapy HIPPS code at a cost of about $2,000 per episode.

    Physician order problems can be the kiss of death to an appeal, notes consultant Lynda Dilts-Benson with Reingruber & Co. in St. Petersburg, FL. That's because if you failed to secure the physician's signed and dated orders before you billed, "you can say good-bye" to the reimbursement for that claim with no recourse, Dilts-Benson says.

    "The third most frequent denial reason code (5F011) is quite alarming to me," agrees consultant M. Aaron Little with BKD in Springfield, MO. "There is no excuse for billing a final claim without verifying the plan of care and all interim/PRN orders have been signed and dated by the physician. This is certainly the most avoidable denial reason code."

    If you see any or all of these denial reasons frequently, they likely point to a communication problem between your financial and clinical departments, Little warns.

    Editor's Note: For the full list of the top ten denial reasons, see Eli's HCW, Vol. XIV, No. 12.

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