Home Health & Hospice Week

Significant therapy visit denials also lead to reduced reimbursement.

Your claims may not have much hope of passing medical review on face-to-face grounds, if the results from one MAC’s recent reviews are any indication.

HHH Medicare Administrative Contractor Palmetto GBA has released the results from reviews of three different HIPPS codes: 1BGP*, 5AGK*, and 5BGK*. And once again, face-to-face-related denials account for the lion’s share of denied reimbursement.

Palmetto reviewed the largest volume of claims under the 1BGP review — 2,847 claims from Nov. 1, 2014, to Jan. 31. Palmetto denied 59 percent of the claims it reviewed. Nearly 65 percent of the dollars denied were due to F2F reasons. 1BGP indicates 11 to 13 therapy visits, a mid-clinical score (2) and mid-functional score (2), notes reimbursement expert M. Aaron Little with BKD in Springfield, Mo.

While it didn’t account for as many dollars as the F2F denials, denial of therapy visits headed up the reasons for denial and downcodes, Palmetto reveals.

Remember: When a reviewer denies a claim based on the F2F, the entire episode’s reimbursement is denied. When a reviewer denies some or even all therapy visits, the HIPPS code often just gets bumped down to a lower therapy level, leaving significant reimbursement remaining.

HIPPS code 5AGK represents 20+ therapies, Clinical Severity Level 1, Functional Severity Level 2, Service Severity Level 1, while 5BGK represents 20+ therapies, Clinical Severity Level 2, Functional Severity Level 2, Service Severity Level 1. (Remember, the service severity “K” when paired with payment grouping “5” loses relevance, because it no longer is “low” since the patient is at 20+ therapies, Little explains.)

Palmetto reviewed far fewer claims in these categories — 22 claims for 5AGK from Dec. 1, 2014 to Feb. 28, and 29 claims for 5GGK.

Overall, Palmetto denied 45 percent of claims in these two categories. F2F denials accounted for 100 percent of dollars in one area and dollar denial rates in the 90s in others, although some other areas were much lower.

Read more about Palmetto’s review on its website at www.palmettogba.com/medicare — choose “J11 MAC Home Health and Hospice” from the left-hand menu, then choose “Results” from the “Medical Review” tab in the left column.