Reason Code 5H162: Provider Did Not Submit All Records Requested

Reason for Denial
For services to be covered by the Medicare program, they must be furnished under a written plan of care, and the plan of care must be established before rendering treatment. The plan can be established by the physician or nonphysician practitioner (NPP), the treating physical therapist, occupational therapist or speech-language pathologist. The NPP can be a physician assistant, nurse practitioner or clinical nurse specialist. (Only a physician can establish a plan of care in a Comprehensive Outpatient Rehabilitation Facility.)

How to Avoid 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:

• At a minimum, the plan of care should include
  • The diagnosis;
  • Long term goals; and
  • Type, amount, duration and frequency of the specific therapy service
• Changes in the plan may be made in writing and must be signed by one of the following:
  • The physician
  • The physical therapist who furnishes the physical therapy services
  • The occupational therapist who furnishes the occupational therapy services
  • The speech-language pathologist who furnishes the speech-language pathology services
  • A registered professional nurse
  • A nurse practitioner
  • A clinical nurse specialist
  • A physician assistant

More Information 

• CMS Internet-Only Manual (IOM), Medicare Benefits Manual Publication 100-02, Chapter 15, Section 220.1.2 (PDF)
• CMS Internet-Only Manual (IOM), Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 C, 42 CFR 424.5(a)(6), Social Security Act 1833(e) (PDF)