Home Health & Hospice Week
MAC Targets More High-Therapy Claims For Review
High payment equals high levels of scrutiny.
Be ready to defend your high-dollar claims, because chances that they’ll go under medical review are increasing.
On the heels of announcing prepay probe reviews of three high-therapy, high-dollar codes (see Eli’s HCW, Vol. XXIII, No. 4), HHH Medicare Ad-ministrative Contractor Palmetto GBA has announ-ced probe reviews for five more high-therapy codes, according to its website.
1. 5AHK*: 20+ therapies, Clinical Severity Level 1, Functional Severity Level 3, Service Sever-ity Level 1
2. 5BGK*: 20+ therapies, Clinical Severity Level 2, Functional Severity Level 2, Service Sever-ity Level 1
3. 5AGK*: 20+ therapies, Clinical Severity Level 1, Functional Severity Level 2, Service Sever-ity Level 1
4. 5BFK*: 20+ therapies, Clinical Severity Level 2, Functional Severity Level 1, Service Sever-ity Level 1
5. 5AFK*: 20+ therapies, Clinical Severity Level 1, Functional Severity Level 1, Service Sever-ity Level 1.
Common theme: Unlike the last batch of codes, these codes Palmetto is targeting have varying clinical, functional and service scores. But they all have a few things in common — the highest level of therapy and high case-mix weights, which equal high reimbursement amounts.
If you rack up a high denial rate, the MAC will notice. "Individual providers with significant denials may be contacted for one-on-one education," Palmetto warns.
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