Home Health & Hospice Week

Warning: EMR templates may be your medical review downfall.

If you think your agency’s claims will pass medical review with flying colors because you’ve nailed face-to-face encounter requirements, you may need to think again.

Why? Another denial reason is giving FTF a run for its money. “Skilled nursing services were not medically necessary” (denial code 5HN18) ranked as the number-one reason for denying home health claims in CGS’ most recently reported quarter of medical reviews. Thirty percent of claims denied from January to March — 271 — were due to this reason, the HHH Medicare Administrative Contractor says in a recent post.

Over at MAC Palmetto GBA, denial code 5F041/5A041 (The documentation submitted was insufficient to support that the skilled nurse service(s) billed was/were reasonable and necessary) accounted for 23 percent of claims — 188 — denied from September 2021 to March 2022. That was second only to FTF as the denial reason (see HCW by AAPC, Vol. XXXI, No. 28), Palmetto notes in a July 28 post to its website.

Under this denial reason, “the skilled nursing visit[s] denied were not covered because the documentation submitted in response to the Additional Development Request (ADR) did not support medical necessity for continuation of skilled services,” Palmetto explains. “The key to Medicare coverage is for the documentation to ‘paint a picture’ of the beneficiary’s overall medical condition indicating the need for skilled service,” the MAC says.

“To determine whether a service is reasonable and necessary, the Medicare home health benefit considers each beneficiary’s unique medical condition,” CGS notes on its Medically Necessary and Reasonable webpage. “The medical record documentation … provide[s] the basis for this determination,” the MAC emphasizes.

“Coverage decisions are always based upon the objective clinical evidence of the beneficiary’s individual need for care,” CGS adds.

A lack of supporting documentation is often due to a common culprit: checkbox-style electronic medical record templates. “Although EMRs are great tools, the use of them can lead clinicians to feel like they documented because they checked a box, when in reality that may not be sufficient,” warns FORVIS consultant Angela Huff in Springfield, Missouri. (FORVIS is the firm formed by the recent merger of BKD and DHG.)

“In doing chart reviews for organizations, I find that the majority of visit notes do not include narrative that is strong enough to paint the full picture,” Huff tells AAPC.

Bottom line: “Reviewers may not be able to fit the pieces together correctly without that solid context from the documenting clinician,” Huff says. “That can lead to denials,” she warns.

Note: CGS and Palmetto’s results articles are at www.cgsmedicare.com/hhh/medreview/hh_denial_reasons.html and www.palmettogba.com/palmetto/jmhhh.nsf/DID/5YLERKAGMY.