Home Health & Hospice Week

Skilled nursing necessity reason slips off top 5 list.

There’s one new denial reason in the TPE list one MAC recently issued.

According to HHH Medicare Administrative Contractor CGS, home health claims under Targeted Probe & Educate saw these top five denial reasons from Oct. 1 2017 to June 30, 2018:

1. Face-to-Face Documentation — 29 percent. (In CGS’s last update, it was 30 percent.)
2. Documentation did not support medical necessity of therapy — 10 percent (18 percent last time).
3. Initial certification invalid — 9 percent (6 percent last time).
4. Plan of care missing/invalid — 9 percent (5 percent last time).
5. Recertification estimate missing/invalid — 9 percent (new).

Dropped: Skilled nursing not medically necessary, at 6 percent last time, did not make it onto this update’s list.

While the top five list is informative, it accounts for only 66 percent of the denial reasons, notes Joe Osentoski, reimbursement recovery & appeals director for QIRT in Troy, Michigan. It would be helpful to make a “Top 10” denial reasons list “to allow agencies to perform more comprehensive record reviews on problem areas before triggering a TPE probe,” Osentoski tells Eli.