2017 Pre-Claim Review (PCR) Data for the state of Illinois

The Pre-Claim Review (PCR) Demonstration for Home Health Services began in Illinois on August 3, 2016. The demonstration was paused on April 1, 2017, as the Centers for Medicare & Medicaid Services (CMS) made revisions to the program to provide flexibility as a result of provider feedback. This article explains data Palmetto GBA collected during the PCR demonstration within the state of Illinois, to include Illinois affirmation rates, claim submission trends, and the top 15 non-affirmation reason descriptions.  

The PCR demonstration permitted providers to submit one or more home health services as defined by HCPCS codes per request. Based on the request, providers could receive a decision of fully provisionally affirmed, partially affirmed, or non-affirmed. During the PCR demonstration, Home Health providers in the state of Illinois submitted 123,873 PCR requests, resulting in a combined fully provisional and partially affirmed rate of 97.5 percent at the conclusion of the demonstration. Excluding the partially affirmed PCR requests, the fully affirmed rate for the state of Illinois was 95.8 percent. A partially affirmed decision indicates at least one service was provisionally affirmed. The 57.5 percent increase of the combined fully and partially affirmed rate from 40 percent was a noticeable improvement from the beginning of PCR in April, 2016. Affirmation rate improvement can be attributed to extensive provider education, as well as assistance from PCR nurse reviewers calling home health agencies to review partially or non-affirmed requests. This allowed the agency to understand what was missing in the PCR submission and resubmit to receive a provisional affirmation.  

During week 24 of the demonstration, ending on January 14, 2017, 88.5 percent of PCR requests received a fully affirmed decision. Overall in week 24, 91.7 percent of PCR requests received a fully affirmed or partially affirmed decision. The chart below identifies the affirmation percentage in the state of Illinois over the course of the demonstration. The blue line represents full provisional affirmation, the red line represents partial affirmations and the green represents a combination of full and partial affirmations.

Percentage of Affirmation Requests - Illinois 

During the PCR demonstration, Palmetto GBA identified a decrease in claim submissions. During the demonstration, Palmetto GBA received an average of 25,025 home health claims per month. After the demonstration was paused for review, Palmetto GBA identified an average increase in monthly claim submissions by greater than 5,000 versus the first three months of the year average.

Below are the top 15 non-affirmation denial reason descriptions from the PCR demonstration in the state of Illinois. The denial reason descriptions, which include the denial explanation and Internet Only Manual (IOM) reference, are listed in descending order.

Non-Affirmation Reason Description
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 4/1/11 and before 01/01/15) was missing. Refer to CMS IOM Publication 100-02, Chapter 7, Section 30.5.1.1 and 30.5.1.2.
Documentation submitted does not include measurable physical therapy treatment goals that are related to the patient's illness/injury/impairment. Refer to CMS IOM Publication 100-02, Chapter 7, Section (30.2.1) and Local Coverage Determination: Home Health Physical Therapy (L34564).
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. Refer to CMS IOM Publication 100-02, Chapter 7, Section 30.5.1.
Documentation submitted does not support skilled nursing services are reasonable and necessary. Refer to CMS IOM Publication 100-02, Chapter 7, Section (40.1).
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. Refer to CMS IOM Publication 100-02, Chapter 7, Section 40.2.1 and 40.2.2 and Local Coverage Determination: Home Health Physical Therapy (L34564).
Documentation submitted does not include specific occupational therapy goals. Refer to CMS IOM Publication 100-02, Chapter 7, Section 40.2.1 and 40.2.4 and Local Coverage Determination: Home Health-Occupational Therapy (L34560).
Documentation submitted does not support a considerable and taxing effort to leave home. Refer to CMS IOM Publication 100-02, Chapter 7, Section (30.1.1).
The physician certification was invalid since the required face-to-face encounter was not related to the primary reason for home health services. Refer to CMS IOM Publication 100-02, Chapter 7, Section 30.5.1.2.
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. Refer to CMS IOM Publication 100-02, Chapter 7, Section 30.2.2
The 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 qualified occupational therapist. Refer to CMS IOM Publication 100-02, Chapter 7, Section 40.2.1 and 40.2.4 and Local Coverage Determination: Home Health-Occupational Therapy (L34560)
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. Refer to CMS IOM Publication 100-02, Chapter 7, Section 30.1.1
There was no valid initial physician's certification of patient eligibility, therefore services on the subsequent episode may not be allowed. Refer to CMS IOM Publication 100-08, Chapter 6, Section 6.2.1.
Documentation submitted does not support a normal inability to leave the home. Refer to CMS IOM Publication 100-02, Chapter 7, Section 30.1.1
The physician recertification estimate of how much longer skilled services are required is missing. Refer to CMS IOM Publication 100-02, Chapter 7, Section 30.5.2
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. Refer to CMS IOM Publication 100-02, Chapter 7, Section 30.2.2.

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