5CHG3 - MR HIPPS Code Change Due to Partial Denial of Therapy

Published 02/26/2019

The services billed were paid at a lower payment level. Based on medical review, the original HIPPS code was changed.

To prevent 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.
  • Based on the medical records submitted for review, some of the therapy visits were not allowed and reimbursement was adjusted due to a partial denial

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