Home Health & Hospice Week

Don’t mess up this condition of payment.

Smart home health agencies will lower their denial rates — and reimbursement losses — by targeting claims’ biggest threat: the face-to-face encounter.

New medical review results from HHH Medicare Administrative Contractor Palmetto GBA show how much FTF troubles plague HHA claims — and thus their bottom lines. In a review of 8,444 claims from 321 providers in the September 2021-to- March 2022 window, Palmetto reviewers denied 820 claims either partially or fully — about 10 percent.

Of those denials, 468 (57 percent) were due to denial code 5FF2F/5TF2F (Face-to-Face Encounter Requirements Not Met), Palmetto reveals in results posted July 28. That’s up from 50 percent in a batch of reviews that the MAC conducted after the COVID-related medical review suspension lifted in August 2021 (see HCW by AAPC, Vol. XXX, No. 38).

The next-highest reasons for denials this time were 5F041/5A041 (The documentation submitted was insufficient to support that the skilled nurse service(s) billed was/were reasonable and necessary) at 23 percent and 5F023/5T023 (No Plan of Care or Certification) at 16 percent, Palmetto says. The rest of the denial reasons accounted for 1 percent or less of denials.

Palmetto’s results do exclude claims from the Review Choice Demonstration states, notes Joe Osentoski with Gateway Home Health Coding & Consulting in Madison Heights, Michigan. Those are Illinois, Ohio, North Carolina, Florida and Texas.

In contrast: Results posted earlier this summer by HHH MAC CGS didn’t rank FTF denials quite as high. Instead, lack of medical necessity for SN services (5HN18) was number one at 30 percent of the roughly 940 claim denials, according to the results for the January-to-March 2022 review period.

Denial code 5HC09 (The initial certification was missing/incomplete/invalid; therefore, the recertification episode is denied) fell second with 23 percent of denials and FTF was ranked third at 18 percent. Two more denial reasons — 5HY01 (The medical documentation submitted did not show that the therapy services were reasonable and necessary and at a level of complexity which requires the skills of a therapist) and 5HH01 (Documentation submitted does not support homebound status) fell at numbers three and four, respectively, with 10 and 6 percent of denials, CGS reports.

For the CGS review, “FTF dropped to their number three ranking,” observes denials and appeals expert Osentoski. “I found this to be unusual,” he tells AAPC.

For FTF, “I just see agencies not performing the most basic function time after time,” Osentoski says. “This piles up denials from MACs, UPICs, and MA plans,” he observes.

“The FTF is a condition of payment,” CGS stresses in its FTF Home Health Denial Fact Sheet. “If the FTF is not done, or not documented sufficiently, claims may be denied,” the MAC warns.

Note: See the medical review results at www.palmettogba.com/palmetto/jmhhh.nsf/DID/5YLERKAGMY and www.cgsmedicare.com/hhh/medreview/hh_denial_reasons.html.