5D650 - No Valid Certification/Recertification Present
The service(s) billed (was/were) not covered because a valid certification/recertification signed by the physician was not included in the medical records submitted for review as required by Medicare.
To prevent this denial:
- In order to avoid unnecessary denials for this reason, when responding to an Additional Documentation Request (ADR), the provider should ensure that the appropriate documentation to support certification/recertification is included and that it is signed by the mental health physician
- The initial certification should be completed at the time of admission or as soon thereafter as the patient’s condition reasonably allows. The physician must provide documentation that the services to be furnished on an inpatient basis can reasonably be expected to improve the patient’s condition or are for diagnostic study. There is no particular language or format required for the certification. It may be submitted on provider generated forms, in progress notes, in the records relating to the stay in question, however, it must be signed by the physician. If the certification is delayed it must be submitted with an explanation or other relevant evidence to justify the delay.
- Recertification should support that all services provided since the previous certification/recertification were, and continue to be, medically necessary that treatment is expected to improve the patient’s condition, or is for diagnostic study. There should be documentation that the patient continues to require, on a daily basis, active treatment and the supervision of inpatient psychiatric staff. The first recertification must be completed as of the twelfth (12th) day of hospitalization. Each subsequent certification may be at intervals established by the psychiatric facility on a case-by-case basis. However, the interval is to be no longer than thirty (30) days.
For more information refer to:
- Code of Federal Regulations, 42 CFR – Section 424.14
- CMS Internet-Only Manuals (IOMs), Medicare Benefit Policy Manual, Publication 100-02, Chapter 2, Section 30.2.1 (PDF, 103 KB)
- CMS Internet-Only Manuals (IOMs), General Information, Eligibility and Entitlement Manual, Publication 100-01, Chapter 4, Sections 10.9 (PDF, 122 KB)
- Psychiatric Inpatient Hospitalization Local Coverage Determinations (LCD – L34570), on the CMS website