Reason Code 5H504: Not Medically Reasonable and Necessary

5H504 — Not Medically Reasonable and Necessary|
The claim was fully or partially denied, as we were unable to determine medical necessity with the documentation submitted for review.

To Prevent This Denial

• Documentation should support treatment of a condition for which the beneficiary was receiving inpatient hospital services or for a condition that arose while receiving care in a SNF for treatment of a condition for which the beneficiary was previously treated in the hospital
• Submit all documentation to support the services billed and the medical necessity of those services. Services must be medically reasonable and necessary and supported by documentation.
• Submit a copy of the qualifying hospital stay transfer/discharge summary that relates to the services provided in the Skilled Nursing Facility (SNF)
• Submit a physician certification and subsequent recertification of the need for continuing daily skilled SNF services
• Submit the corresponding MDS for each RUG code billed. If more than one RUG code is billed, an MDS for each RUG code must be submitted for review. This may include all MDS from the start of care through the dates of service billed.
• Submit all documentation used to complete each MDS. This includes the documentation to cover the look back periods for each MDS submitted.
• Submit dated physician’s orders for all services billed, including services provided during the look back period (s). Orders for services rendered during the look back period(s), written prior to the look back period, must be submitted with the documentation.
• Include any separate forms used for documentation of medication, wound care, staging of wounds, therapy minutes, weights, vital signs, intake and output, enteral feedings, nutritional consults, percentage of meals consumed, bladder and bowel function with the submitted records
• Ensure any changes in condition or treatment that would warrant daily skilled care are documented and submitted for review. This documentation includes, but is not limited to, nurse’s notes, social worker notes, nutritional services, activity reports, progress notes, consultations, laboratory and X-ray reports, treatment plans.
• Documentation should include the beneficiary’s functional level and mental status, changes in treatment or medications, the skilled services provided in response to physician’s orders, and visits from the physician or other professional personnel
• Documentation in the form of checklists must include documentation of the beneficiary’s response to the services rendered
• Clinical documentation that furnishes a picture of the beneficiary’s care needs and response to treatment helps to establish the need for Part A services in a skilled nursing facility

More Information

• CMS Internet-Only Manual (IOM), General Information, Eligibility and Entitlement Manual, Publication 100-01, Chapter 4, Sections 10 and 10.6 (PDF)
• CMS Internet-Only Manual (IOM), Medicare Benefit Policy Manual, Pub 100-02, Chapter 8, Sections 30 and 40 (PDF)