Reason Code 5H165: The Documentation Submitted Did Not Include the Required Certifications or Recertification

Reason for Denial
For services to be covered by the Medicare program, the plan of care must be certified by the physician or nonphysician practitioner (NPP). Certification means that the physician or NPP has signed and dated the plan of care or some other document that indicates approval of the plan of care. No valid physician certification or recertification was submitted.

How to Avoid This Denial
A certification or recertification should be submitted for review.

• The certification must indicate that the beneficiary
  • Needed the type of therapy provided
  • Was under the care of a physician, nurse practitioner, clinical nurse specialist or physician assistant; and
  • Was treated under a valid plan of care
• The initial certification should be signed/dated within 30 days of the first day of treatment (including the evaluation)
• The recertification must occur at least every 90 calendar days
• The signature may be written, electronic, or stamped. If the physician fails to date his/her signature, staff can add “Received Date” in writing or with a stamp.
• Clear copies of the medical records should be submitted

For more information refer to CMS Internet-Only Manual (IOM), Medicare Benefit Policy Manual, Publication 100- 02, Chapter 15, 220.1.3 (PDF).