Pre-Payment Review Results for Home Health Low Utilization for October to December 2023

Pre-Payment Review Results for Home Health Low Utilization for Targeted Probe and Educate (TPE) for October to December 2023

The Centers for Medicare & Medicaid Services (CMS) implemented the TPE process for Home Health Low Utilization. The reviews with edit effectiveness are presented here for Ala., Ark., Ga., Ind., Ky., La., N.M., Okla. and S.C.

Cumulative Results

Probe One Findings 

Risk Category
The risk categories for Home Health Low Utilization are defined as:

 
Top Denial Reasons

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
• 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
• 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:

1. Occurred within the required time frame
2. Was related to the primary reason the patient requires home health services
3. 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
• Discharge summary and comprehensive assessment

Resources

• 42 Code of Federal Regulations (CFR) — Sections 424.22(a)(1)(v)(A), 424.22(d)(2)
• CMS IOM, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 7, Section 30.5.1.1 (PDF)
   

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 Additional Documentation Request (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.

Resources

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

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 (POC) 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 POC is included and that it is legibly signed and dated by the physician prior to billing
• A POC 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/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
  • The services were furnished while the individual was under the care of a physician
• Since the certification is closely associated with the POC, 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 POC 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. 

Resources

• 42 Code of Federal Regulations (CFR) — Sections 424.22, 409.41, 409.42, 409.43
• CMS IOM Pub. 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4, Section 30 (PDF)
• CMS IOM Pub. 100-02, Medicare Benefit Policy Manual, Chapter 7, Section 30 (PDF)
   

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 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.

Resources

• 42 Code of Federal Regulations (CFR) — Sections 424.22
• CMS IOM, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 7, Sections 30.2.2 and 30.2.5 (PDF)
   

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 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 ADR to request reopening. Do not resubmit the claim.

How to Avoid This Denial

• Be aware of the ADR date and the need to submit medical records within 45 days of the ADR date
• Submit the medical records as soon as the 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 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 ADR.
• Gather all of the information needed for the claim and submit it all at one time 
• Attach a copy of the ADR request to each individual claim 
• If responding to multiple 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

Resources

• CMS IOM Pub. 100-04, Medicare Claims Processing Manual, Chapter 34 (PDF)
• CMS IOM Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.2 (PDF)
   

Education
Palmetto GBA offers providers selected for TPE an individualized education session to discuss each claim denial. This is an opportunity to learn how to identify and correct claim errors. A variety of education methods are offered such as webinar sessions, web-based presentations or teleconferences. Other education methods may also be available. Providers do not have to be selected for TPE to request education. If education is desired, please complete the Education Request Form (PDF).

Next Steps
Providers found to be non-compliant (major risk category/denial rate of 21–100 percent) at the completion of TPE Probe 1 will advance to Probe 2, and providers found to be non-compliant (major risk category/denial rate of 21–100 percent) at the completion of TPE Probe 2 will advance to Probe 3 of TPE after at least 45 days from completing the 1:1 post-probe education call date.