HHH Denial Reason Code Crosswalk

5FF2F

The physician certification was invalid since the required face-to-face encounter was missing / incomplete / untimely.

The physician certification was invalid since the required face-to-face encounter document (Actual Encounter visit for face-to-face encounter visit for admissions on/or after 1/1/15, or the narrative for admission on/or after 4/1/11 and before 01/01/15) was missing.

HH01A

The physician certification was invalid since the required face-to-face encounter document (actual clinical note for the face-to face encounter visit for admissions on or after 1/1/15, or the narrative for admissions on or after 4/1/11and before 1/1/15) was missing.

The physician certification was invalid since the required face-to-face encounter was untimely and/or the certifying physician did not document the date of the encounter. 

HH01B

The physician certification was invalid since the required face-to-face encounter document was untimely and/or the certifying physician did not document the date of the encounter.

The physician certification was invalid since the face-to-face was not performed by an approved practitioner.

HH01C

The physician certification was invalid since the face-to-face encounter was not performed by an approved practitioner.

The physician certification was invalid since the required face-to-face encounter was not related to the primary reason for home health services.

HH01D

The physician certification was invalid since the required face-to-face encounter was not related to the primary reason for home health services.

5F023

No physician's Plan of Care and no certification present

The physician's Plan of Care was missing.

HH02A

The Plan of Care was missing.

The content of the Plan of Care submitted was insufficient.

HH02B

The content of the Plan of Care submitted was insufficient.

The Plan of Care submitted was not signed timely by a qualified physician.

HH02I OR HH02C

The Plan of Care submitted was not signed timely by a qualified physician. OR The Plan of Care submitted was not signed.

Missing physician certification/recertification submitted.

HH02D

Missing physician certification/recertification.

The physician certification/recertification submitted does not support skilled need.  Documentation in the certifying physician's medical record and/or the acute/post-acute care facility's medical records (if the patient was directly admitted to home health) shall be used as the basis for certification of home health eligibility.

HH02E

The physician certification/recertification submitted does not support skilled need. Documentation in the certifying physician's medical records and/or the acute/post-acute care facility's medical records (if the patient was directly admitted to home health) shall be used as the basis for certification of home health eligibility.

The initial plan of care was not submitted or was invalid, therefore services on the subsequent episode may not be allowed.

HH05A OR HH05B

The initial Plan of Care was not submitted with the documentation therefore, services on the subsequent episode may not be allowed. OR There was no valid initial physician’s certification of patient eligibility therefore; services on the subsequent episode may not be allowed.        

The physician certification/recertification submitted does not support homebound status.  Documentation in the certifying physician's medical records (if the patient was directly admitted to home health) shall be used as the basis for certification of home health eligibility.

HH02F

The physician certification/recertification submitted does not support homebound status. Documentation in the certifying physician's medical records and/or the acute/post-acute care facility's medical records (if the patient was directly admitted to home health) shall be used as the basis for certification of home health eligibility.

The Physician recertification estimate of how much longer skilled services are required is missing. 

HH02G

The physician recertification estimate of how much longer skilled services are required is missing.

5FT10

Documentation submitted does not support homebound status.

Documentation submitted does not support homebound criteria-one is met.  For criteria-one to be met, the patient must either because of illness or injury, need the aid of supportive devices such as crutches, canes, wheelchairs, and walker; the use of special transportation; or the assistance of another person in order to leave their place of residence; or have a condition such that leaving his or her home is medically contraindicated.

HH03A

Documentation submitted does not support homebound criteria-one is met. For criteria-one to be met, the patient must either because of illness or injury, need the aid of supportive devices such as crutches, canes, wheelchairs, and walker; the use of special transportation; or the assistance of another person in order to leave their place of residence; or have a condition such that leaving his or her home is medically contraindicated.

Documentation submitted does not support a normal inability to leave the home.

HH04A

Documentation submitted does not support a normal inability to leave the home.

Documentation submitted does not support a considerable and taxing effort to leave home.

HH04B

Documentation submitted does not support a considerable and taxing effort to leave home.

5F001/

5T001

Physician's plan of care is present, but no certification.

Missing or invalid narrative describing the clinical justification for management and evaluation of the care plan.

 

 

5F251/

5A251

Documentation does not support that skilled management and evaluation (M&E) of care plan is reasonable and necessary.

The skilled nursing visit for management and evaluation of the patient's plan of care was not reasonable and necessary.

  

 

5F072/

5T072

Medicare requires that all services be ordered by a physician.  The denied visits were not ordered, or exceeded the physician's orders.

Orders (including discipline, duration, frequency, treatment, legible, signed/dated appropriately) were not submitted to cover all of the skilled nursing visits billed.

HH06M OR HH06A

An order for skilled nursing services is invalid because it does not contain either the type of services to be provided, the professional who will provide the services, or the frequency of the services.   OR    Missing an order for skilled nursing services.

Orders (including discipline, duration, frequency, treatment, legible, signed/dated appropriately) were not submitted to cover all of the physical therapy visits billed.

HH06N OR  HH06C

An order for physical therapy services is invalid because it does not contain either the type of services to be provided, the professional who will provide the services or the frequency of the services.    OR    Missing an order for physical therapy services.

Orders (including discipline, duration, frequency, treatment, legible, signed/dated appropriately) were not submitted to cover all of the occupational therapy visits billed.

HH06P OR HH06I

An order for occupational therapy services is invalid because it does not contain either the type of services to be provided, the professional who will provide the services or the frequency of the services.   OR   Missing an order for occupational therapy services.

Orders (including discipline, duration, frequency, treatment, legible, signed/dated appropriately) were not submitted to cover all of the speech language pathology visits billed.

HH06H  OR  HH06F OR  HH06O 

 (1) Documentation submitted does not support speech language pathology services as reasonable and necessary and at a level which requires the skills of a qualified speech therapist.    OR  (2)  Missing an order for speech language pathology services.   OR   (3)  An order for speech language pathology services is invalid because it does not contain either the type of services to be provided, the professional who will provide the services or the frequency of the services.

Orders (including discipline, duration, frequency, treatment, legible, signed/dated appropriately) were not submitted to cover all of the medical social worker visits billed.

HH07G OR   HH07A

An order for the social worker services is invalid because it does not contain either the type of services to be provided, the professional who will provide the services or the frequency of the services.   OR   Missing an order for the social worker services.

Orders (including discipline, duration, frequency, treatment, legible, signed/dated appropriately) were not submitted to cover all of the home health aide visits billed.

HH07H  OR  HH07D

An order for Home Health Aide Services is invalid because it does not contain either the type of services to be provided, the professional who will provide the services or the frequency of the services.  OR   Missing an order for the Home Health Aide Services.

5FT49/

5AT49

To qualify for Medicare home health services the beneficiary needs to have intermittent skilled nursing care visits.  When the medical need is only for a single skilled nursing visit, Medicare cannot pay for the nurse because the intermittent requirement is not met.

The intermittent requirement is not met. The skilled nurse is ordered one time without a qualifying skill.

  

 

5FT5J/

5AT5J

 Insufficient documentation of hours to determine if the part-time requirement is met.

 The intermittent requirement is not met.  The IN and/or OUT times of the skilled nurse and/or home health aide were not submitted in the medical record. Therefore, the part-time aspect of intermittency was not met.

  

 

5FE39/

5AE39

Documentation does not support exemption from endpoint for daily insulin administration. 

The intermittent requirement is not met.  Documentation does not support exemption from endpoint for daily insulin administration as no treatment order submitted/no documentation of why patient cannot self- inject insulin/no documentation of why patient's caregiver cannot or will not administer insulin.

 

 

5FT5L/

5AT5L

These services are denied because it does not meet the part time or intermittent criteria. Home health aide care exceeds 28/35 hours.

The intermittent requirement is not met.  Home health aide care exceeded 28/35 hours. 

 

 

5FT5K/

5AT5K

These services are denied because it does not met the part time or intermittent criteria. Skilled nursing care exceeds 28/35 hours.

The intermittent requirement is not met.  Skilled nursing care exceeded 28/35 hours.

 

 

5F070/

5T070

No documentation of services rendered.

The documentation for physical therapy visit(s) was not submitted in the medical record.

  

 

The documentation for occupational therapy visit(s) was not submitted in the medical record.

 

 

The documentation for speech language pathology visit(s) was not submitted in the medical record.

  

 

The documentation submitted in the medical record for medical social worker visits was missing/illegible/incomplete.

  

  

The documentation submitted in the medical record for home health aide visits was missing/illegible/incomplete.

  

5FTDR/

5TTDR

The therapy documentation does not support that the Assessment, Measurement and Documentation of Therapy Effectiveness was completed at the required interval(s) and/or was not completed by a therapist.

The required initial assessment/30 day reassessment was not submitted in the medical record/the assessment or reassessment was completed by a therapy assistant/no credentials were provided for person completing the initial assessment/30 day reassessment.

HH06E

Documentation submitted does not support physical therapy services are reasonable and necessary and at a level of complexity which requires the skills of a qualified physical therapist.

5F041/

5A041

Medicare requirements are that skilled observation is needed as long as the reasonable potential for change in condition exists. There was no further need for skilled observation.

The documentation submitted was insufficient to support that the skilled nurse service(s) billed was/were reasonable and necessary.

HH06B

Documentation submitted does not support skilled nursing services are reasonable and necessary.

5F171/

5A171

Documentation does not support why the injectable medication could not be given orally.

The medication was available in oral form. There was no documentation as to why the patient was not able to take the medication orally.

HH06B

Documentation submitted does not support skilled nursing services are reasonable and necessary.

5F181/

5A181

Documentation does not support that the wound care required the skills of a nurse.

The services performed by the skilled nurse related to the wound care were not reasonable and necessary.

HH06B

Documentation submitted does not support skilled nursing services are reasonable and necessary.

5F111/

5A111

Documentation does not support the frequency of venipuncture.

The sole purpose of the visit was to perform venipuncture; which is not covered by Medicare as a qualifying skill.

HH06B

Documentation submitted does not support skilled nursing services are reasonable and necessary.

5F141/

5A141

Vitamin B12 is not reasonable and necessary based on diagnosis.

The administration of Vitamin B12 injection was not covered. There was no diagnosis to support Vitamin B12 injections.

HH06B

Documentation submitted does not support skilled nursing services are reasonable and necessary.

5F151/

5A151

Documentation does not support more than one Vitamin B12 injection in the same month.

The administration of Vitamin B12 injection(s) was not covered. The frequency ordered was not reasonable and necessary.

HH06B

Documentation submitted does not support skilled nursing services are reasonable and necessary.

5FIN1/

5AIN1

Documentation does not support why insulin can't be self injected.

The documentation does not support why insulin can't be self-injected and/or the non-availability of a willing or able caregiver.

HH06B

Documentation submitted does not support skilled nursing services are reasonable and necessary.

5F101/

5A101

The Medicare program does not consider prefilling of insulin syringes to be a skilled nursing service.

The prefilling of insulin syringes/medication planners is not a skilled service.

HH06B

Documentation submitted does not support skilled nursing services are reasonable and necessary.

5F042/

5A042

Monthly Mediport flush without administration of medication is not medically necessary.

The monthly Mediport flush without administration of medication was not reasonable and necessary.

HH06B

Documentation submitted does not support skilled nursing services are reasonable and necessary.

5F161/

5A161

Based on the documentation submitted, the type of medication received is not accepted by Medicare as an effective treatment for the medical condition.

The type of medication received was not accepted as an effective treatment for the medical condition

HH06B

Documentation submitted does not support skilled nursing services are reasonable and necessary.

5FEP1/

5AEP1

Documentation does not support that Epogen administration was medically necessary.

The documentation does not support why Epogen cannot be self injected and/or the non-availability of a willing or able caregiver.

HH06B

Documentation submitted does not support skilled nursing services are reasonable and necessary.

5F031/

5A301

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.

The documentation submitted for physical therapy visits does not support service as reasonable and necessary. The initial physical therapy evaluation/physical therapy treatment plan was not submitted and/or did not include goals stated in objective, measurable terms signed by the certifying physician and those goals with their expected date(s) of accomplishment signed by the therapist. 

HH06D

Documentation submitted does not include measurable physical therapy treatment goals that are related to the patient’s illness/injury/impairment.

The documentation submitted for physical therapy visit(s) does not support service as reasonable and necessary. For subsequent physical therapy episodes, the initial physical therapy evaluation note/all required physical therapy re-evaluation or re-assessment notes were not submitted for review. 

HH06E

Documentation submitted does not support physical therapy services are reasonable and necessary and at a level of complexity which requires the skills of a qualified physical therapist.

The documentation submitted for physical therapy visits does not support that physical therapy services provided were at a level of complexity which requires the skills of a therapist. The physical therapy visit(s) in question was/were: 

HH06E

Documentation submitted does not support physical therapy services are reasonable and necessary and at a level of complexity which requires the skills of a qualified physical therapist.

The documentation submitted for occupational therapy visits does not support service as reasonable and necessary. The initial occupational therapy evaluation/occupational therapy treatment plan was not submitted and/or did not include goals stated in objective, measurable terms signed by the certifying physician and those goals with their expected date(s) of accomplishment signed by the therapist.

HH06K

Documentation submitted does not include specific occupational therapy goals.

The documentation submitted for occupational therapy visits does not support that occupational therapy services provided were at a level of complexity which requires the skills of a therapist. The occupational therapy visit(s) in question was/were:

HH06L

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

The documentation submitted for speech language pathology visits does not support service as reasonable and necessary. The initial speech language pathology evaluation/speech language pathology treatment plan was not submitted and/or did not include goals stated in objective, measurable terms signed by the certifying physician and signed by the therapist.

HH06G

The documentation for speech language pathology services does not contain specific goals that are measurable.

 

The documentation submitted for speech language pathology therapy visits does not support that speech language pathology therapy services provided were at a level of complexity which requires the skills of a therapist. The speech language pathology visit(s) in question was/were:

HH06H

Documentation submitted does not support speech language pathology services as reasonable and necessary and at a level which requires the skills of a qualified speech therapist.

5F401/

5A401

Information provided does not support the medical necessity for medical social worker visit(s).

Documentation submitted does not support social worker services are reasonable and necessary.

HH07C

Documentation submitted does not support social worker services are reasonable and necessary.

5F451/

5A451

Based on our review of the information provided, the home health aide visits specified did not include personal care services or services that were necessary to maintain the beneficiary's health or help with treatments.

Documentation does not support frequency or number of home health visits/that personal care was provided/that services provided were appropriate for home health aide. The home health aide visit(s) in question was/were:

HH07H

An order for Home Health Aide Services is invalid because it does not contain either the type of services to be provided, the professional who will provide the services or the frequency of the services.

5ADSD

These services are denied as there was no qualifying skilled service provided

The home health aide services was/were not covered because the qualifying skilled service(s) was/were denied medically.

HH07E

Home Health Aide services cannot be allowed without a qualifying service.

The medical social worker services was/were not covered because the qualifying skilled service(s) was/were denied medically.

HH07B

Social worker services cannot be allowed without a qualifying service.

The supply charges were not covered because the qualifying skilled services were denied medically.

  

 

5TDSD

These services are denied as there was no qualifying skilled service provided

The home health aide services was/were not covered because the qualifying skilled service(s) was/were denied technically.

HH07E

Home Health Aide services cannot be allowed without a qualifying service.

The medical social worker services was/were not covered because the qualifying skilled service(s) was/were denied technically.

HH07B

Social worker services cannot be allowed without a qualifying service.

The supply charges were not covered because the qualifying skilled services were denied technically.

  

 

5F074/

5T074

Medicare can cover home health services only when intermittent skilled nursing care or physical or speech therapy is also needed. Since the beneficiary did not need these services, no payment can be made for the services listed.

The occupational therapy visit(s) was/were not continuing. There was no documentation of need for skilled nursing care, speech-language pathology or physical therapy in the current or prior certification period.

HH06J

Occupational therapy visits cannot be allowed without a qualifying service.

No qualifying service was billed. There was no documentation of need for skilled nursing care, speech-language pathology, or physical therapy in the current or prior certification period.

HH06J

Occupational therapy visits cannot be allowed without a qualifying service.

5FNOA/

5ANOA

Medical necessity not supported as there is no OASIS present.

The OASIS was not present in the state repository.

  

 

5FNOF/

5ANOF

Medical necessity not supported as an incorrect OASIS was submitted.

The OASIS found in the state repository was the transfer oasis.

  

 

The OASIS found in the state repository was the discharge oasis.

  

 

The OASIS found in the state repository was for the subsequent dates of service.

  

 

The HIPPS code billed does not match the HIPPS code found in the state repository.

 

 

5CHG1

MR downcode/

documentation contradicts OASIS M item(s).

 The HIPPS code was recoded due to contradiction of OASIS M Items.

 

 

5CHG2

MR downcode/provider billed higher category than OASIS M item(s) billed.

        The HIPPS code was recoded due to provider billed higher category than OASIS M Item(s) totaled.

  

 

5CHG3

Partial denial for therapy resulting in MR downcode.

The HIPPS code was recoded due to a partial denial for therapy.

 

 

5CHG5

Based on medical review of the documentation, the HIPPS code has been recoded, resulting in a change to Medicare payment.

The HIPPS code was recoded resulting in an upcode.

 

 

5DOW4

Partial denial resulting in a LUPA.

The claim was partially denied resulting in a LUPA.