Home Health & Hospice Week

Therapy visit medical necessity breaks into top 5 reasons in latest quarter.

Expect face-to-face to rise from its already high percentage of denials under the Targeted Probe and Educate medical review program.

HHH Medicare Administrative Contractor CGS has released its most recent TPE results (see story, p. 42). The MAC lists these top denial reasons for the quarter ended Dec. 31, 2018:

1. Face-to-Face missing/incomplete/untimely — 27 percent
2. Initial certification invalid — 12 percent
3. Medical records were not received — 10 percent
4. Plan of care missing/invalid — 8 percent
5. Therapy visits not medically necessary — 8 percent

Difference: Compared to the previous quarter, “Recertification estimate missing/invalid” has dropped off the list. As of Jan. 1, Medicare no longer requires the recert length estimate on POCs, notes Joe Osentoski with Quality in Real Time in Troy, Michigan.

Instead, last quarter’s number-five item (POC missing/invalid) has moved into the number-four spot and a new reason, “Therapy visits not medically necessary,” has slid into the number-five spot. Items one through three remain the same at nearly the same percentages.

F2F already ranks as the top denial reason, and at 27 percent is well ahead of the next denial reason — cert invalid at 12 percent.

But the F2F denials are likely to rise even higher as home health agencies fix their other technical denial difficulties. Currently, reviewers look first for technical items, then move on to more in-depth denial reasons under medical necessity and eligibility issues.

“I still have frustration with agencies not removing every technical denial reason prior to billing,” Osentoski says. Those reasons include “plan of care, certification content, signed and dated orders, etc. They have nearly full control over these items.”