Postpayment Service-Specific Probe Results for Home Health for April through June 2021

Published 09/28/2021

Postpayment Service-Specific Probe Results for Home Health in Alabama, Arkansas, Georgia, Indiana, Kentucky, Louisiana, Mississippi, New Mexico, Oklahoma, South Carolina, Tennessee and Other States for April through June 2021

Palmetto GBA performed service-specific postpayment probe review on home health. This edit was set in Alabama, Arkansas, Georgia, Indiana, Kentucky, Louisiana, Mississippi, New Mexico, Oklahoma, South Carolina, Tennessee and other states. The results for the probe review, for claims processed April through June, 2021, are presented here.

Cumulative Results
A total of 2,517 claims were reviewed in Alabama, Arkansas, Georgia, Indiana, Kentucky, Louisiana, Mississippi, New Mexico, Oklahoma, South Carolina, Tennessee and other states combined. A total of 434 of the claims were either completely or partially denied, resulting in an overall claim denial rate of 17.24 percent. The total dollars reviewed were $6,200,066.99, of which $947,114.30 were denied, resulting in a charge denial rate of 15.28 percent. Overall, there were a total of 141 auto-denied claims in the region. The top denial reasons identified, based on dollars denied, and number of occurrences were:

Percent of Total Denials

Denial Code

Denial Description

Number of Occurrences

49.77%

5FF2F/5TF2F

Face-to-Face Encounter Requirements Not Met

216

19.82%

5F023/5T023

No Plan of Care or Certification

86

13.59%

5FNOA/5ANOA

No Initial OASIS/OASIS Present for SCIC HIPPS Code

59

5.53%

5F041/5A041

The Documentation Submitted Was Insufficient to Support That the Skilled Nurse Service(S) Billed Was/Were Reasonable and Necessary

24

2.53%

5CHG3/5CHG3

Medical Review HIPPS Code Change Due to Partial Denial of Therapy

11

Alabama Results
A total of 194 claims were reviewed, with 37 of the claims either completely or partially denied, resulting in a claim denial rate of 19.07 percent. The total dollars reviewed were $430,999.89, of which $70,606.50 were denied, resulting in a charge denial rate of 16.38 percent. The top denial reasons were identified, based on dollars denied, and the number of occurrences were:

Percent of Total Denials

Denial Code

Denial Description

Number of Occurrences

51.35%

5FF2F/5TF2F

Face-to-Face Encounter Requirements Not Met

19

24.32%

5F023/5T023

No Plan of Care or Certification

9

8.11%

5FNOA/5ANOA

No Initial OASIS/OASIS Present for SCIC HIPPS Code

3

5.41%

5CHG3/5CHG3

Medical Review HIPPS Code Change Due to Partial Denial of Therapy

2

5.41%

5TDSD/5ADSD

Dependent Services Denied (Qualifying Service Denied Medically, or Qualifying Service Denied Technically)

2

Arkansas Results
A total of 214 claims were reviewed, with 13 of the claims either completely or partially denied, resulting in a claim denial rate of 6.07 percent. The total dollars reviewed were $553,295.38, of which $24,725.60 were denied, resulting in a charge denial rate of 4.47 percent. The top denial reasons were identified, based on dollars denied, and the number of occurrences were:

Percent of Total Denials

Denial Code

Denial Description

Number of Occurrences

69.23%

5FF2F/5TF2F

Face-to-Face Encounter Requirements Not Met

9

15.38%

5F301/5A301

Information Provided Does Not Support the Medical Necessity for Therapy Services

2

7.69%

5CHG3/5CHG3

Medical Review HIPPS Code Change Due to Partial Denial of Therapy

1

7.69%

5F023/5T023

No Plan of Care or Certification

1

Georgia Results
A total of 120 claims were reviewed, with nine of the claims either completely or partially denied, resulting in a claim denial rate of 7.50 percent. The total dollars reviewed were $304,929.36, of which $21,931.50 were denied, resulting in a charge denial rate of 7.19 percent. The top denial reasons were identified, based on dollars denied, and the number of occurrences were:

Percent of Total Denials

Denial Code

Denial Description

Number of Occurrences

33.33%

5FF2F/5TF2F

Face-to-Face Encounter Requirements Not Met

3

33.33%

5F023/5T023

No Plan of Care or Certification

3

22.22%

5FNOA/5ANOA

No Initial OASIS/OASIS Present for SCIC HIPPS Code

2

11.11%

5FT10/5AT10

Homebound Requirement Not Met (Subject to Waiver)

1

Indiana Results
A total of 530 claims were reviewed, with 107 of the claims either completely or partially denied, resulting in a claim denial rate of 20.19 percent. The total dollars reviewed were $1,436,216.98, of which $262,277.87 were denied, resulting in a charge denial rate of 18.26 percent. The top denial reasons were identified, based on dollars denied, and the number of occurrences were:

Percent of Total Denials

Denial Code

Denial Description

Number of Occurrences

60.75%

5FF2F/5TF2F

Face-to-Face Encounter Requirements Not Met

65

18.69%

5FNOA/5ANOA

No Initial OASIS/OASIS Present for SCIC HIPPS Code

20

9.35%

5F023/5T023

No Plan of Care or Certification

10

2.80%

5DOW4/5DOW4

Partial Denial Resulting in a LUPA

3

1.87%

5CHG3/5CHG3

Medical Review HIPPS Code Change Due to Partial Denial of Therapy

2

Kentucky Results
A total of 222 claims were reviewed, with 31 of the claims either completely or partially denied, resulting in a claim denial rate of 13.96 percent.. The total dollars reviewed were $573,265.00, of which $78,884.23 were denied, resulting in a charge denial rate of 13.76 percent. The top denial reasons were identified, based on dollars denied, and the number of occurrences were:

Percent of Total Denials

Denial Code

Denial Description

Number of Occurrences

61.29%

5FF2F/5TF2F

Face-to-Face Encounter Requirements Not Met

19

25.81%

5F023/5T023

No Plan of Care or Certification

8

6.45%

5FNOA/5ANOA

No Initial OASIS/OASIS Present for SCIC HIPPS Code

2

3.23%

5F072/5T072

No Physician’s Order for Services or More Than Ordered

1

3.23%

5FNOF/5ANOF

Incorrect OASIS Submitted

1

Louisiana Results
A total of 359 claims were reviewed, with 57 of the claims either completely or partially denied, resulting in a claim denial rate of 15.88 percent. The total dollars reviewed were $787,849.23, of which $104,094.61 were denied, resulting in a charge denial rate of 13.21 percent. The top denial reasons were identified, based on dollars denied, and the number of occurrences were:

Percent of Total Denials

Denial Code

Denial Description

Number of Occurrences

40.35%

5FF2F/5TF2F

Face-to-Face Encounter Requirements Not Met

23

24.56%

5F023/5T023

No Plan of Care or Certification

14

10.53%

5F041/5A041

The Documentation Submitted Was Insufficient to Support That the Skilled Nurse Service(S) Billed Was/Were Reasonable and Necessary

6

8.77%

 5FNOA/5ANOA

No Initial OASIS/OASIS Present for SCIC HIPPS Code

5

5.26%

 5CHG3/5CHG3 Medical Review HIPPS Code Change Due to Partial Denial of Therapy

3

Mississippi Results
A total of 28 claims were reviewed, with five of the claims either completely or partially denied, resulting in a claim denial rate of 17.86 percent. The total dollars reviewed were $73,577.90, of which $9,421.88 were denied, resulting in a charge denial rate of 12.81 percent. The top denial reasons were identified, based on dollars denied, and the number of occurrences were:

Percent of Total Denials

Denial Code

Denial Description

Number of Occurrences

40.0%

5FNOA/5ANOA

No Initial OASIS/OASIS Present for SCIC HIPPS Code

2

20.0%

5CHG5/5CHG5

Medical Review HIPPS Code Change Due to Up Coding

1

20.0%

5F041/5A041

The Documentation Submitted Was Insufficient to Support That the Skilled Nurse Service(S) Billed Was/Were Reasonable and Necessary

1

20.0%

5FF2F/5TF2F

Face-to-Face Encounter Requirements Not Met

1

New Mexico Results
A total of 103 claims were reviewed, with 36 of the claims either completely or partially denied, resulting in a claim denial rate of 34.95 percent. The total dollars reviewed were $283,007.62, of which $87,153.51 were denied, resulting in a charge denial rate of 30.80 percent. The top denial reasons were identified, based on dollars denied, and the number of occurrences were:

Percent of Total Denials Denial Code Denial Description Number of Occurrences
63.89% 5FF2F/5TF2F Face-to-Face Encounter Requirements Not Met 23
27.78% 5F023/5T023 No Plan of Care or Certification 10
2.78% 5F301/5A301 Information Provided Does Not Support the Medical Necessity for Therapy Services 1
2.78% 5F001/5T001 No Physician’s Certification 1
2.78% 5F072/5T072 No Physician’s Order for Services or More than Ordered 1

Oklahoma Results
A total of 478 claims were reviewed, with 93 of the claims either completely or partially denied, resulting in a claim denial rate of 19.46 percent. The total dollars reviewed were $1,001,783.38, of which $156,973.33 were denied, resulting in a charge denial rate of 15.67 percent. The top denial reasons were identified, based on dollars denied, and the number of occurrences were:

Percent of Total Denials

Denial Code

Denial Description

Number of Occurrences

37.63%

5FF2F/5TF2F

Face-to-Face Encounter Requirements Not Met

34

20.43%

5F023/5T023

No Plan of Care or Certification

19

15.05%

5FNOA/5ANOA

No Initial OASIS/OASIS Present for SCIC HIPPS Code

14

15.05%

5F041/5A041

The Documentation Submitted Was Insufficient to Support That the Skilled Nurse Service(S) Billed Was/Were Reasonable and Necessary

14

5.38%

5TDSD/5ADSD

Dependent Services Denied (Qualifying Service Denied Medically, or Qualifying Service Denied Technically)

5

South Carolina
A total of 78 claims were reviewed, with 10 of the claims either completely or partially denied, resulting in a claim denial rate of 12.82 percent. The total dollars reviewed were $225,059.75, of which $28,875.12 were denied, resulting in a charge denial rate of 12.83 percent. The top denial reasons were identified, based on dollars denied, and the number of occurrences were:

Percent of Total Denials

Denial Code

Denial Description

Number of Occurrences

50.0%

5FF2F/5TF2F

Face-to-Face Encounter Requirements Not Met

5

20.0%

5F023/5T023

No Plan of Care or Certification

2

20.0%

5DOW4/5DOW4

Partial Denial Resulting in a LUPA

2

10.0%

5FNOA/5ANOA

No Initial OASIS/OASIS Present for SCIC HIPPS Code

1

Tennessee Results
A total of 134 claims were reviewed, with 19 of the claims either completely or partially denied, resulting in a claim denial rate of 14.18 percent. The total dollars reviewed were $339,575.10, of which $50,964.59 were denied, resulting in a charge denial rate of 15.00 percent. The top denial reasons were identified, based on dollars denied, and the number of occurrences were:

Percent of Total Denials

Denial Code

Denial Description

Number of Occurrences

42.11%

5FNOA/5ANOA

No Initial OASIS/OASIS Present for SCIC HIPPS Code

8

31.58%

5F023/5T023

No Plan of Care or Certification

6

26.32%

5FF2F/5TF2F

Partial Denial Resulting in a LUPA

5

Other State Results
A total of 57 claims were reviewed from other states, with 17 of the claims either completely or partially denied, resulting in a claim denial rate of 29.82 percent. The total dollars reviewed were $190,507.40, of which $51,205.56 were denied, resulting in a charge denial rate of 26.88 percent. The top denial reasons were identified, based on dollars denied, and the number of occurrences were:

Percent of Total Denials

Denial Code

Denial Description

Number of Occurrences

52.94%

5FF2F/5TF2F

Face-to-Face Encounter Requirements Not Met

9

23.52%

5F023/5T023

No Plan of Care or Certification

4

11.76%

5FNOA/5ANOA

No Initial OASIS/OASIS Present for SCIC HIPPS Code

2

11.76%

5CHG3/5CHG3

MR HIPPS Code Change Due to Partial Denial of Therapy

2

Denial Reasons and Prevention Recommendations

5FF2F/5TF2F — Face-to-Face Encounter Requirements Not Met

Reason for Denial
The services billed were not covered because the documentation submitted for review did not include (adequate) documentation of a face-to-face encounter.

How to Avoid This Denial
Specific documentation related to face-to-face encounter requirements must be submitted for review. This includes, but is not limited to, the following:

  • A face-to-face encounter must occur no more than 90 days prior to the home health start of care date or within 30 days of the start of the home health care;
  • Encounter was related to the primary reason the patient requires home health services; and
  • Encounter was performed by a physician or allowed nonphysician practitioner

The certifying physician must also document the date of the face-to-face encounter.

The face-to-face encounter can be performed by:

  • The certifying physician;
  • The physician who cared for the patient in an acute or post-acute care facility (from which the patient was directly admitted to home health);
  • A nurse practitioner or a clinical nurse specialist who is working in collaboration with the certifying physician or the acute/post-acute care physician; or
  • A certified nurse midwife or physician assistant under the supervision of the certifying physician or the acute/post-acute care physician

The certifying physician’s and/or the acute/post-acute care facility’s medical record for the patient must contain the actual clinical note for the face-to-face encounter visit that demonstrates that the encounter:

  • Occurred within the required time frame;
  • Was related to the primary reason the patient requires home health services; and
  • Was performed by an allowed provider type

This information can be found most often in, but is not limited to the following examples:

  • Discharge summary;
  • Progress note;
  • Progress note and problem list; or
  • Discharge summary and comprehensive assessment

More Information

5F023/5T023 — No Plan of Care or Certification

Reason for Denial
The services billed were not covered because the home health agency (HHA) did not have the plan of care established and approved by a physician, as required by Medicare, included in the medical records submitted for review and/or the service(s) billed were not covered because the documentation submitted did not include the physician’s signed certification or recertification.

How to Avoid This Denial

  • Ensure that the appropriate plan of care (POC) is included and that it is legibly signed and dated by the physician prior to billing
  • A plan of care refers to the medical treatment plan established by the treating physician with the assistance of the home health skilled professional. The POC contains all pertinent diagnoses, the patient’s mental status, the types of services, supplies and equipment required, the frequency of visits to be made, prognosis, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, all medications and treatments, safety measures to protect against injury, instructions for timely discharge or referral, and any additional items the HHA or physician chooses to include.
  • Ensure that the signed certification or recertification is submitted when responding to an ADR
  • The physician must certify that:
    • The home health services were required because the individual was confined to his or her home and needs intermittent skilled nursing care, physical therapy and/or speech-language pathology, or continues to need occupational therapy;
    • A plan for furnishing such services to the individual has been established and is periodically reviewed by a physician; and
    • The services were furnished while the individual was under the care of a physician
  • Since the certification is closely associated with the plan of care, the same physician who establishes the plan must also certify to the necessity for home health services. Certifications must be obtained at the time the POC is established or as soon thereafter as possible. There is no requirement that a specific form must be used, as long as the intermediary can determine that this requirement is met. When requesting reimbursement for a claim, the provider must have the certification on file and be able to submit this information if medical records are requested by the intermediary.
  • The physician must recertify at intervals of at least once every 60 days that there is a continuing need for services and should estimate how long services will be needed. The recertification should be obtained at the time the plan of care is reviewed and must be signed by the same physician who signs the POC. When requesting reimbursement for a claim, the provider must have the recertification on file and be able to submit this information if medical records are requested by the intermediary.

More Information

5FNOA/5ANOA — No Initial OASIS/OASIS Present for SCIC HIPPS Code

Reason for Denial
Medical necessity was not supported as there is no Outcome and Assessment Information Set (OASIS) present in the state repository for the initial HIPPS code billed on the claim.

How to Avoid This Denial
To avoid denials for this reason, the provider should ensure that the OASIS that generated the HIPPS codes on the claim is submitted with the medical records in response to an Additional Development Request (ADR).

Under the Prospective Payment System (PPS), an OASIS is a regulatory requirement. The OASIS that generated the initial HIPPS code is necessary to determine the medical necessity of the level of care billed. Appropriate payment for the entire episode cannot be determined without the OASIS for the initial HIPPS code. As a result, all the services billed are non-covered.

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5F041/5A041 — The Documentation Submitted Was Insufficient to Support That the Skilled Nurse Service(s) Billed Was/Were Reasonable and Necessar

Reason for Denial
The skilled nursing visit 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.

Initially, skilled nursing services were required to observe and assess the beneficiary’s medical condition and response to the plan of care. 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.

Skilled observation and assessment beyond a three-week period may be justified when documentation supports the likelihood of further complications or an acute episode. However, observation and assessment are not reasonable and necessary when the documentation indicated that the abnormal findings are part of a longstanding pattern of the patient’s condition and there is no attempt to change the treatment to resolve them.

How to Avoid This Denial
Submit all documentation related to the services rendered and billed to Medicare which supports the medical necessity of the services. A legible signature and date signed is required on all documentation necessary to support orders and medical necessity. Refer to the following:

  • CMS Internet-Only Manual (IOM), Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4 (PDF, 652.50 KB)
  • CMS Medicare Learning Network (MLN) Matters article MM6698 — Signature Guidelines for Medical Review Purposes (PDF, 76.57 KB)
  • Medicare Medical Records: Signature Requirements, Acceptable and Unacceptable Practices
  • Use the most appropriate ICD-10-CM codes to identify the beneficiary’s medical diagnosis/diagnoses
  • Submit documentation to support the need for skilled care. Some reasons for services may include, but are not limited to, the following:
    • New onset or acute exacerbation of diagnosis (include documentation to support signs and symptoms and the date of the new onset or acute exacerbation)
    • New and/or changed prescription medications — new medications: those the beneficiary has not taken recently, i.e., within the last 30 days. Changed medications: those, which have a change in dosage, frequency, or route of administration within the last 60 days.
    • Hospitalizations (include date and reason)
    • Acute change in condition (be specific and include changes in treatment plan as a result of changes in medical condition, e.g., physician contact, medication changes)
    • Changes in caregiver status or an unstable caregiving situation (e.g., involvement of many services or community resources, unsafe or unclean environment which interferes with putting the plan into action)
    • Complicating factors (i.e., simple wound care on lower extremity for a beneficiary with diabetic peripheral angiopathy)
    • Inherent complexity of services; therefore, the services can be safely and effectively provided only by a skilled professional
    • Lack of knowledge or understanding of the beneficiary’s care, which requires initial skilled teaching and training of a beneficiary, the beneficiary’s family or caregiver on how to manage the beneficiary’s treatment regime
    • Reinforcement of previous teaching when there is a change in the beneficiary’s physical location (i.e., discharged from hospital to home)
    • Any type of reteaching due to a significant change in a procedure, the beneficiary’s medical condition, when the beneficiary’s caregiver is not properly carrying out the task, or other reasons which may require skilled reteaching and training activities
    • The need for a nurse to administer an injection of a self-injectable medication such as insulin or Calcimar. Clinical documentation needs to indicate:
      • The beneficiary’s inability to self-inject and the non-availability of a willing/able caregiver
      • The appropriate diagnosis to warrant administration of the medication
      • Laboratory results (if required to meet Medicare criteria)
      • Dosage of the medication
    • The need for foley/suprapubic catheter changes and/or assessment/instruction regarding complications
    • The need for gastrostomy tube changes and/or assessment/instruction regarding complications
    • The need for administration of IM/IV medications based on medical necessity, supporting diagnosis, and accepted standards of medical practice
    • Dressing changes for complicated wound care including documentation (at least weekly) of wound location, size, depth, drainage, and complaints of pain
    • The need for management and evaluation of a complex care plan. Answering “yes” to the following questions may be helpful in determining this need:
      • Is the patient at high risk for hospitalization or exacerbation of a health problem if the plan of care is not implemented properly (e.g., multiple medical problems or diagnosis, limitations in activities of daily living or mental status, cultural barriers, history of repeated hospitalizations)?
      • Does the patient have a complex, unskilled care plan (e.g., many medications, treatments, use of complex or multiple pieces of equipment, unusual use of supplies)?
      • Is there an unstable caregiving situation (e.g., involvement of many services or community resources, unsafe or unclean environment that interferes with putting the plan into action)?
      • Does it require the skills of a registered nurse or a qualified therapist to ensure safe and appropriate implementation of the plan of care?

More Information

5CHG3 — Medical Review HIPPS Code Change Due to Partial Denial of Therapy

Reason for Denial
The services billed were paid at a lower payment level. Based on medical review of the records submitted, some of the therapy visits billed were not allowed. Reimbursement was adjusted due to a partial denial of therapy and the original HIPPS code was changed.

How to Avoid This Denial
Under the Prospective Payment System (PPS), Medicare reimbursement rates are based on the patient’s health condition and care needs. In order to receive a higher level of payment based on therapy services, there should be an adequate number of payable therapy visits to meet the threshold. This may include one type of therapy or a combination of occupational, speech-language pathology, or physical therapy services.

  • Submit orders to cover the therapy visits billed
  • Submit documentation to support the need for skilled therapy services
  • Submit all documentation related to the therapy services rendered

More Information

5TDSD/5ADSD — Dependent Services Denied (Qualifying Service Denied Medically) (Qualifying Service Denied Technically)

Reason for Denial
In order to allow dependent services, a qualifying skilled service such as nursing, physical therapy, speech language pathology and/or continuing occupational therapy must be ordered and medically necessary. Since the qualifying skilled services was denied/non-covered, the supportive services were also denied/non-covered.

How to Avoid This Denial
Ensure that the qualifying skilled service documentation submitted meets all technical requirements and supports the medical necessity of the services billed when responding to an Additional Development Request (ADR). 

More Information

5DOW4 — Partial Denial Resulting in a LUPA

Reason for Denial
Based on the medical records submitted for review, a portion of the services provided was denied. This resulted in a Low Utilization Payment Adjustment (LUPA).
A LUPA is an episode with four or fewer visits. The payments are based on the wage adjusted per visit amount for each of the visits rendered instead of the full episode amount.

How to Avoid This Denial
When responding to an Additional Development Request (ADR), ensure the documentation submitted for review supports all criteria for all services billed.

More Information

5F301/5A301 — Information Provided Does Not Support the Medical Necessity for Therapy Services

Reason for Denial
The medical documentation submitted did not show that the therapy services were reasonable and necessary and at a level of complexity which requires the skills of a therapist.

How to Avoid This Denial
Ensure that the documentation submitted supports the medical necessity of the therapy services when responding to an ADR.

Skilled therapy services must be reasonable and necessary to the treatment of the patient’s illness or injury within the context of the patient’s unique medical condition. To be considered reasonable and necessary for the treatment of the illness or injury these services must be:

  • Consistent with the nature and severity of the illness or injury, the patient’s particular medical needs, including the requirement that the amount, frequency, and duration of the services must be reasonable;
  • Considered, under accepted standards of medical practice, to be specific, safe, and effective treatment for the patient’s condition;
  • Provided with the expectation, based on the assessment of the patient’s rehabilitation potential, that the condition of the patient will improve materially in a reasonable and generally predictable period of time, or the services are necessary to the establishment of a safe and effective maintenance program

Services involving activities for the general welfare of any patient, e.g., general exercises to promote overall fitness or flexibility and activities to provide diversion or general motivation do not constitute skilled therapy.

More Information

  • Code of Federal Regulations, 42 CFR — Sections 409.33, 409.42 and 409.44 
  • CMS Internet-Only Manual (IOM), Pub 100-02, Medicare Benefit Policy Manual, Chapter 7, Sections 30.5.1.2 and 40.2.1 (PDF, 765.44 KB)
     

5F072/5T072 — No Physician’s Order for Services or More than Ordered

Reason for Denial 
Medicare requires that all services be ordered (including discipline, duration, frequency, treatment, legible, signed/dated appropriately) by a physician. The denied visits were not ordered or exceeded the physician's orders.

How to Avoid This Denial

  • When responding to an Additional Development Request (ADR), verify orders for all services rendered and billed are included with the medical records.
  • Ensure physician orders for all services billed are obtained prior to providing the service and prior to billing the final payment claim to Medicare.

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5FNOF/5ANOF – Incorrect OASIS Submitted

Reason for Denial
The services billed were not covered because the home health agency did not submit the appropriate Outcome and Assessment Information Set (OASIS) for the HIPPS code billed on the claim. Medical necessity not supported as an incorrect OASIS was submitted. The OASIS found in the state repository was the transfer/discharge or for subsequent dates of service) OASIS.

How to Avoid This Denial
The provider should ensure that the electronic OASIS that generated the HIPPS code for the claim is submitted to the state repository. This OASIS should also be submitted with the medical records in response to an Additional Development Request (ADR). 

Under the Prospective Payment System (PPS), an OASIS is a regulatory requirement. If the home health agency does not submit the OASIS, the medical reviewer cannot determine the medical necessity of the level of care billed and no Medicare payment can be made for the services.

More Information


5FT10/5AT10 — Homebound Requirement Not Met (Subject to Waiver)

Reason for Denial
The services billed were not covered because the medical records submitted for review did not support homebound status. Documentation must indicate and support the beneficiary is unable to leave home.

How to Avoid This Denial
The provider should submit documentation that reflects that it is a taxing effort for the beneficiary to leave the home. A beneficiary is considered to be homebound if there exists a condition due to illness or injury that restricts the ability to leave the place of residence except with the aid of supportive devices such as crutches, canes, wheelchairs, and walkers, the use of special transportation, or the assistance of another person or if leaving home is medically contraindicated.

More Information

5CHG5 — Medical Review HIPPS Code Change Due to Up Coding

Reason for Denial
The services billed were paid at a higher payment level. Reimbursement was adjusted due to an up code and the original HIPPS code was changed.

How to Avoid This Denial
For more information, refer to: 

5F001/5T001 — No Physician’s Certification

Reason for Denial
The service(s) billed (was/were) not covered because the documentation submitted either did not include the physician’s signed certification/recertification or did not indicate that the physician who signed the plan of care was the same physician who signed the certification or recertification.

How to Avoid This Denial
Ensure that the attending physician signs and dates the certification or recertification and that this information is submitted when responding to an Additional Development Request (ADR) and the physician who signs the plan of care, also signs the certification or recertification.

The physician must certify that: 

  • The home health services were required because the individual was confined to his/her home and needs intermittent skilled nursing care, physical therapy and/or speech-language pathology, or continues to need occupational therapy;
  • A plan for furnishing such services to the individual has been established and is periodically reviewed by a physician; and
  • The services were furnished while the individual was under the care of a physician.

Since the certification is closely associated with the plan of care, the same physician who establishes the plan must also certify to the necessity for home health services. Certifications must be obtained at the time the plan of care is established or as soon thereafter as possible. There is no requirement that a specific form must be used, as long as the intermediary can determine that this requirement is met. When requesting reimbursement for a claim, the provider must have the certification on file and be able to submit this information if medical records are requested by the intermediary. 

The physician must recertify at intervals of at least once every 60 days that there is a continuing need for services and should estimate how long services will be needed. The recertification should be obtained at the time the plan of care is reviewed and must be signed by the same physician who signs the plan of care. When requesting reimbursement for a claim, the provider must have the recertification on file and be able to submit this information if medical records are requested by the intermediary. 

More Information

56900 — Auto Deny — Requested Records Not Submitted Timely

Reason for Denial
The services billed were not covered because the documentation was not received in response to the Additional Documentation Request (ADR) and, therefore, we were unable to determine the medical necessity of the service billed. The provider has 45 days from the date the ADR was generated to respond with medical records. If less than 120 days after denial notification on the remittance advice, submit records to the contractor requesting records at the address listed on the original Additional Development Request (ADR) to request reopening. Do not resubmit the claim.

  • Be aware of the Additional Development Request (ADR) date and the need to submit medical records within 45 days of the ADR date
  • Submit the medical records as soon as the Additional Development Request (ADR) is received
  • Monitor the status of your claims in Direct Data Entry (DDE) and begin gathering the medical records as soon as the claim goes to the location of SB6001
  • Return the medical records to the address on the Additional Development Request (ADR). Be sure to include the appropriate mail code or station number. This ensures that your responses are promptly routed to the Medical Review department. Fax and electronic data submissions are also accepted as indicated on the Additional Development Request (ADR).
  • Gather all the information needed for the claim and submit it all at one time
  • Attach a copy of the Additional Development Request (ADR) request to each individual claim
  • If responding to multiple Additional Development Requests (ADRs), separate each response and attach a copy of the ADR to each individual set of medical records. Make sure each set of medical records is individually identifiable and bound securely to ensure that no documentation is detached or lost. Do not use paper clips.
  • Do not mail packages C.O.D.; we cannot accept them

More Information

The Next Steps
The service-specific postpayment medical review edits for Home Health Services in Alabama, Arkansas, Georgia, Indiana, Kentucky, Louisiana, Mississippi, New Mexico, Oklahoma, South Carolina, Tennessee and other states will be continued based on moderate charge denial rates and medium to high impact severity errors. If significant billing aberrancies are identified, provider-specific review may be initiated.

If you are dissatisfied with a claim determination you have the right to request an appeal. Palmetto GBA encourages you to review the documentation originally submitted, and if you believe you have additional supporting documentation you may include this information with your appeal. For more information related to the appeals process please refer to the Redetermination: 1st Level Appeal form (PDF, 233 KB) form on the Palmetto GBA website.

Questions regarding this medical review can be directed to the Palmetto GBA Provider Contact Center at 855–696–0705.


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