Part A Inpatient Hospital Medical Review Top Denial Reason Codes: July-September 2017

We encourage all providers to review this information when filing claims to prevent denials and to ensure their claims are processed timely.  The following information affects North Carolina, South Carolina, Virginia and West Virginia Part A providers.

Rank
Denial Code
# Claims Denied
Denial Code Description
1
5D700
400
No Valid Plan of Treatment Present
2
5J504
397
Need for Service/Item Not Medically and Reasonably Necessary
3
56900
132
Auto Denial - Requested Records not Submitted
4
5D800
42
Documentation Submitted Does Not Support Medical Necessity for Inpatient Psychiatric Services
5
5D650
13
No Valid Certification/Recertification Present
6
5J503
13
No Orders for Inpatient Admission
7
5D161
10
No Physician's Orders
8
5J502
7
Info Submitted Does Not Support Dates Billed

Denial Reasons and Prevention Recommendations
5D700 – No Valid Plan of Treatment Present
The service(s) billed (was/were) not covered because a valid treatment plan established and approved by a physician was not included in the medical records submitted for review as required by Medicare.

To prevent this denial:
In order to avoid unnecessary denials for this reason, when responding to an Additional Development Request (ADR), the provider should ensure that the appropriate treatment plan is included and that it is signed by the physician and the mental health professionals contributing to it.

The treatment plan should be developed within the first 3 days of admission. The focus should be individualized to the patient’s specific strengths and problems as identified in the physician’s psychiatric evaluation, psychosocial and nursing assessments. It should contain a substantiated diagnosis; both short-term and long-range measurable, functional, time-framed goals directed at the individual problems identified as the cause for the patient’s admission; a list of any specific treatment modalities to be utilized in the active treatment of the patient; and a listing of the responsibilities of each member of the treatment team as he/she relates to the plan.

Treatment plan updates should show the treatment plan to be reflective of active treatment, as indicated by documentation of changes in the type, amount, frequency, and duration of the treatment services rendered as the patient moves toward expected outcomes. Treatment plan updates should be documented at least weekly, as the physician and treatment team assess the patient’s current clinical status and make necessary changes. Lack of progress and its relationship to active treatment and reasonable expectation of improvement should also be noted.

For more information, refer to:

  • Code of Federal Regulations, 42 CFR – Section 482.61.
  • CMS Internet-Only Manuals (IOMs), Medicare Benefit Policy Manual, Chapter 2, Publication 100-02, Section 30.3.
  • Psychiatric Inpatient Hospitalization Local Coverage Determinations (LCD – L34570), on the Palmetto GBA website.

5J504 – Need For Services Not Medically and Reasonably Necessary
The claim has been fully or partially denied as the documentation submitted for review did not support the medical necessity of the services provided.

To prevent this denial:
Documentation and tips that may be helpful to avoid future denials for this reason may include, but are not limited to, the following:

  • Submit documentation to support that services were medically necessary on an inpatient basis instead of a less intensive setting.
  • Documentation should include all clinical information for the dates of service billed such as physician progress notes, physical examinations, assessments, diagnostic tests and laboratory test results, history and physical, nurse’s notes, consultations, surgical procedures, orders and discharge summary and any other documentation to support the inpatient admission.
  • Include documentation of services, medication and medical interventions performed in the Emergency Department.
  • For elective surgical procedures, include documentation to support the necessity of the procedure including pre-surgical interventions and outcomes.

For more information, refer to:

  • CMS Internet-Only Manuals (IOMs), Medicare Program Integrity Manual, Publication 100-08, Chapter 6, Section 6.5.
  • CMS Internet-Only Manuals (IOMs), Medicare Benefit Policy Manual, Publication 100-02, Chapter 1, Sections 1 and 10.

56900 - Auto Deny – Requested Records Not Submitted Timely 
The services billed were not covered because the claim was not submitted or not submitted timely in response to an Additional Documentation Request (ADR). When an ADR is generated, the provider has 45 days from the date the ADR was generated to respond with medical records. In accordance with CMS instructions, if the documentation needed to make a medical review determination is not received within 45 days from the date of the documentation request, Palmetto GBA will make a medical review determination based on the available medical documentation. If the claim is denied, payment will be denied or an overpayment will be collected.

To prevent 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.
  • 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 bound securely with one staple in the upper left corner or a rubber band 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.

For more information, refer to Medical Review Progressive Corrective Action (PCA) Process article on the Palmetto GBA website.

5D800 – Inpatient Psychiatric Services Not Medically Necessary
Documentation submitted for review did not support the medical necessity for inpatient psychiatric services.

To prevent this denial:

  • In order to avoid denials for this reason, the documentation must provide clear evidence that the acute psychiatric condition being evaluated or treated requires active treatment, including a combination of services such as intensive nursing and medical intervention, psychotherapy, occupational and activity therapy. Patients must require inpatient psychiatric hospitalization services at levels of intensity and frequency exceeding what may be rendered in an outpatient setting, including psychiatric partial hospitalization. There must be evidence of failure at, inability to benefit from, or unacceptable risk in an outpatient treatment setting.
  • In addition you should submit a complete Psychiatric Evaluation. This evaluation should be completed within 60 hours of the patient’s admission to the Psychiatric facility. It should include a medical history, record of mental status; note the onset of the current illness and circumstances leading to admission; describe the behaviors and attitudes of the patient; estimate the intellectual functioning, memory and orientation; provide an inventory of the patient’s assets in a descriptive fashion. In addition to the evaluation, progress notes from all modalities should be submitted in the medical record.

For further information on the above Medicare coverage issue, references include, but are not limited to, these resources:

  • CMS Internet-Only Manuals (IOMs), Medicare Benefit Policy Manual, Publication 100-02, Chapter 2, Sections 20 & 30.
  • Code of Federal Regulations, 42 CFR – Section 412.27 & 482.61.
  • Psychiatric Inpatient Hospitalization Local Coverage Determinations (LCD – L34570), on the Palmetto GBA website.

5D650 – No Valid Certification/Recertification Present
The service(s) billed (was/were) not covered because a valid certification/recertification signed by the physician was not included in the medical records submitted for review as required by Medicare.

To prevent this denial:

  • In order to avoid unnecessary denials for this reason, when responding to an Additional Development Request (ADR), the provider should ensure that the appropriate documentation to support certification/recertification is included and that it is signed by the mental health physician.
  • The initial certification should be completed at the time of admission or as soon thereafter as the patient’s condition reasonably allows. The physician must provide documentation that the services to be furnished on an inpatient basis can reasonably be expected to improve the patient’s condition or are for diagnostic study. There is no particular language or format required for the certification. It may be submitted on provider generated forms, in progress notes, in the records relating to the stay in question, however, it must be signed by the physician. If the certification is delayed it must be submitted with an explanation or other relevant evidence to justify the delay.
  • Recertification should support that all services provided since the previous certification/recertification were, and continue to be, medically necessary that treatment is expected to improve the patient’s condition, or is for diagnostic study. There should be documentation that the patient continues to require, on a daily basis, active treatment and the supervision of inpatient psychiatric staff. The first recertification must be completed as of the 12th day of hospitalization. Each subsequent certification may be at intervals established by the psychiatric facility on a case-by-case basis. However, the interval is to be no longer than 30 days.

For more information refer to:

  • Code of Federal Regulations, 42 CFR – Section 424.14.
  • CMS Internet-Only Manuals (IOMs), Medicare Benefit Policy Manual, Publication 100-02, Chapter 2, Section 30.2.1.
  • CMS Internet-Only Manuals (IOMs), Medicare General Information, Eligibility and Entitlement Manual, Publication 100-01, Chapter 4, Section 10.9.
  • Psychiatric Inpatient Hospitalization Local Coverage Determinations (LCD – L34570), on the Palmetto GBA website.

5J503 – No Physician Orders for Inpatient Admission
The claim has been fully or partially denied as the documentation submitted for review did not include a physician order to admit the patient. Services that are not ordered by the physician are not reasonable and necessary.

To prevent this denial:
Documentation and tips that may be helpful to avoid future denials for this reason may include, but are not limited to, the following:

  • Physician’s order to admit to inpatient services should be clearly identified in the medical records. This order may be located within the history and physical, progress note, emergency room report and/or verbal order signed and dated by the physician.
  • The signature must be legible and should include the practitioner’s first and last name. Also include applicable credentials such as MD, PA, or DO.
  • Electronic signatures are acceptable. Valid examples include, but are not limited to, the following: “Electronically signed by John Smith, M.D.”, “Authenticated by John Smith, M.D.” or “Verified by John Smith, M.D.”.
  • Orders for inpatient admission written by a non-physician practitioner must be cosigned by the attending physician.

For more information, refer to CMS Internet-Only Manuals (IOMs), Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4.

5D161 - No Physician’s Orders
This claim was fully or partially denied because there were no physician’s orders submitted for review for all or some of the services billed.

To prevent this denial:

  • A physician’s order should be submitted for review with the request for copies of medical records.
  • A legible signature is required on all documentation necessary to support orders and medical necessity.
  • The copy of the order should be legible and dated.
  • Make sure any orders submitted for review are for the dates of service billed.

For more information, refer to:

  • Code of Federal Regulations, 42 CFR – Section 410.32
  • CMS Internet-Only Manuals (IOMs), Medicare Program Integrity Manual, Publication 100-08, Chapter 3, Section 3.3.2.4

5J502: Information Submitted Does Not Support Dates Billed
This claim has been fully denied as the documentation submitted for review was not for the billing period requested in the Additional Documentation Request (ADR). As a result, there were no orders for services or documentation of medical necessity for services billed.

To prevent this denial:
Documentation and tips that may be helpful to avoid future denials for this reason may include, but are not limited to, the following:

  • Ensure that the correct documentation is submitted for medical review by developing a procedure for staff to follow when preparing information in response to an ADR.
  • Develop a form checklist to be used when responding to an additional development request to ensure appropriate information is submitted for the dates billed.

For more information, refer to:

  • CMS Internet-Only Manuals (IOMs), Medicare Program Integrity Manual, Publication 100-08, Chapter 6 – Intermediary MR Guidelines for Specific Services, Section 6.5.
  • CMS Internet-Only Manuals (IOMs), Medicare Program Integrity Manual, Publication 100-08, Chapter 3 – Verifying Potential Errors and Taking Corrective Actions, Section 3.4. 

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