Postpayment Service-Specific Probe Results for Home Health for October through December 2020

Published 04/15/2021

Palmetto GBA performed a service-specific postpayment probe review on home health. This edit was set in Alabama, Arkansas, Arizona, Georgia, Indiana, Kansas, Kentucky, Louisiana, Massachusetts, Michigan, Missouri, Mississippi, Nebraska, New Mexico, Oklahoma, Pennsylvania and Tennessee. The results for the probe review for claims processed October through December 2020 are presented here.

Cumulative Results
A total of 185 providers were placed on edit in Alabama, Arkansas, Arizona, Georgia, Indiana, Kansa, Kentucky, Louisiana, Massachusetts, Michigan, Missouri, Mississippi, Nebraska, New Mexico, Oklahoma, Pennsylvania, and Tennessee combined. A total of 322 claims were reviewed, with 35 of the claims either completely or partially denied, resulting in an overall claim denial rate of 10.87 percent. The total dollars reviewed was $760,071.92 of which $70,319.51was denied, resulting in a charge denial rate of 9.25 percent. Overall, there was a total of 13 auto denied claims in the region.

Alabama Results
A total of six providers were placed on edit in Alabama. A total of seven claims were reviewed, with one of the claims either completely or partially denied. This resulted in a claim denial rate of 14.29 percent. The total dollars reviewed was $14,469.65 of which $1,536.02 was denied, resulting in a charge denial rate of 10.62 percent. The top denial reasons were identified, based on dollars denied.

Percent of Total Denials	Denial Code	Denial Description
100.00%	5F023	No Plan of Care or Certification

In order to provide more specific information regarding the denial reasons identified above, a second level of detail was obtained during Medical Review. Each claim that is reviewed may contain more than one type of “granular” error finding. The individual error findings shown below are listed in decreasing order of occurrence, grouped according to the major denial categories listed above.

Denial Code	Denial Description	Specific “Granular” Denial Findings	Number of Occurrences
5F023	No Plan of Care or Certification	No Plan of Care or Certification	1

Arkansas Results
A total of 11 providers were placed on edit in Arkansas. A total of 20 claims were reviewed, with three of the claims either completely or partially denied. This resulted in a claim denial rate of 15.0 percent. The total dollars reviewed was $46,238.24 of which $4,528.07 was denied, resulting in a charge denial rate of 9.79 percent. The top denial reasons were identified, based on dollars denied.

Percent of Total Denials	Denial Code	Denial Description
66.67%	5FF2F	Face-to-Face Encounter Requirements Not Met
33.33%	5ADSD	Dependent Services Denied (Qualifying Service Denied Medically)

Denial Code	Denial Description	Specific “Granular” Denial Findings	Number of Occurrences
5FF2F	Face-to-Face Encounter Requirements Not Met	Face-to-Face Encounter Requirements Not Met	2
5ADSD	Dependent Services Denied (Qualifying Service Denied Medically)	Dependent Services Denied	1

Arizona Results
A total of one provider was placed on edit in Arizona. A total of two claims were reviewed, with 0 of the claims either completely or partially denied. This resulted in a claim denial rate of 0 percent. The total dollars reviewed was $5,973.23 of which $0.00 was denied, resulting in a charge denial rate of 0 percent. The top denial reasons were identified based on dollars denied.

Percent of Total Denials	Denial Code	Denial Description
N/A	N/A	N/A

Denial Code	Denial Description	Specific “Granular” Denial Findings	Number of Occurrences
N/A	N/A	N/A	N/A

Georgia Results
A total of six providers were placed on edit in Georgia. A total of 14 claims were reviewed, with 0 of the claims either completely or partially denied. This results in a claim denial rate of 0.0%. The total dollars reviewed was $37,365.58 of which $0.00 was denied, resulting in a charge denial rate of 0 percent. The top denial reasons were identified based on dollars denied.

Percent of Total Denials	Denial Code	Denial Description
N/A	N/A	N/A

Denial Code	Denial Description	Specific “Granular” Denial Findings	Number of Occurrences
N/A	N/A	N/A	N/A

Indiana Results
A total of 30 providers were placed on edit in Indiana. A total of 46 claims were reviewed, with 11 of the claims either completely or partially denied. This results in a claim denial rate of 23.91 percent. The total dollars reviewed was $117,643.31 of which $25,648.48 was denied, resulting in a charge denial rate of 21.80 percent. The top denial reasons were identified based on dollars denied.

Percent of Total Denials	Denial Code	Denial Description
81.82%	5FF2F	Face-to-Face Encounter Requirements Not Met
9.09%	5FNOA	Partial Denial or Full Denial One Reason — No OASIS Assessment Submitted
9.09%	5DOW4	Partial Denial Resulting in a LUPA

Denial Code	Denial Description	Specific “Granular” Denial Findings	Number of Occurrences
5FF2F	Face-to-Face Encounter Requirements Not Met	Face-to-Face Encounter Requirements Not Met	9
5FNOA	Partial Denial or Full Denial One Reason — No OASIS Assessment Submitted	No Initial OASIS/OASIS Present for SCIC HIPPS Code	1
5DOW4	Partial Denial Resulting in a LUPA	Partial Denial Resulting in a LUPA	1

Kansas Results
A total of one provider was placed on edit in Kansas. A total of one claim was reviewed, with 0 of the claims either completely or partially denied. This results in a claim denial rate of 0 percent. The total dollars reviewed was $3,069.68 of which $0.00 was denied, resulting in a charge denial rate of 0 percent. The top denial reasons were identified, based on dollars denied.

Percent of Total Denials	Denial Code	Denial Description
N/A	N/A	N/A

Denial Code	Denial Description	Specific “Granular” Denial Findings	Number of Occurrences
N/A	N/A	N/A	N/A

Kentucky Results
A total of 28 providers were placed on edit in Kentucky. A total of 52 claims were reviewed, with 5 of the claims either completely or partially denied. This results in a claim denial rate of 9.62%. The total dollars reviewed was $134,189.12 of which $3,283.40 was denied, resulting in a charge denial rate of 2.45 percent. The top denial reasons were identified based on dollars denied.

Percent of Total Denials	Denial Code	Denial Description
40.00%	5FF2F	Face-to-Face Encounter Requirements Not Met
20.00%	5F023	No Plan of Care or Certification
20.00%	5FNOA	Partial Denial or Full Denial One Reason — No OASIS Assessment Submitted
20.00%	5DOW4	Partial Denial Resulting in a LUPA

Denial Code	Denial Description	Specific “Granular” Denial Findings	Number of Occurrences
5FF2F	Face-to-Face Encounter Requirements Not Met	Face-to-Face Encounter Requirements Not Met	2
5F023	No Plan of Care or Certification	No Plan of Care or Certification	1
5FNOA	Partial Denial or Full Denial One Reason — No OASIS Assessment Submitted	No Initial OASIS/OASIS Present for SCIC HIPPS Code	1
5DOW4	Partial Denial Resulting in a LUPA	Partial Denial Resulting in a LUPA	1

Louisiana Results
A total of 21 providers were placed on edit in Louisiana. A total of 44 claims were reviewed, with one of the claims either completely or partially denied. This results in a claim denial rate of 2.27%. The total dollars reviewed was $84,899.17 of which $1,868.10 was denied, resulting in a charge denial rate of 2.2 percent. The top denial reasons were identified based on dollars denied.

Percent of Total Denials	Denial Code	Denial Description
100.00%	5F023	Face-to-Face Encounter Requirements Not Met

Denial Code	Denial Description	Specific “Granular” Denial Findings	Number of Occurrences
5F023	Face-to-Face Encounter Requirements Not Met	No Plan of Care or Certification	1

Massachusetts Results
A total of three providers were placed on edit in Massachusetts. A total of 11 claims were reviewed, with one of the claims either completely or partially denied. This results in a claim denial rate of 9.09%. The total dollars reviewed was $35,509.47 of which $7,013.84 was denied, resulting in a charge denial rate of 19.75 percent. The top denial reasons were identified based on dollars denied.

Percent of Total Denials	Denial Code	Denial Description
100.00%	5FF2F	No Plan of Care or Certification

Denial Code	Denial Description	Specific “Granular” Denial Findings	Number of Occurrences
5FF2F	No Plan of Care or Certification	Face-to-Face Encounter Requirements Not Met	1

Michigan Results
A total of one provider were placed on edit in Michigan. A total of one claim were reviewed, with 0 of the claims either completely or partially denied. This results in a claim denial rate of 0 percent. The total dollars reviewed was $2,144.10 of which $0.00 was denied, resulting in a charge denial rate of 0 percent. The top denial reasons were identified based on dollars denied.

Percent of Total Denials	Denial Code	Denial Description
N/A	N/A	N/A

Denial Code	Denial Description	Specific “Granular” Denial Findings	Number of Occurrences
N/A	N/A	N/A	N/A

Missouri Results
A total of one provider was placed on edit in Missouri. A total of one claim was reviewed, with 0 of the claims either completely or partially denied. This results in a claim denial rate of 0 percent. The total dollars reviewed was $2,560.85 of which $0.00 was denied, resulting in a charge denial rate of 0 percent. The top denial reasons were identified based on dollars denied.

Percent of Total Denials	Denial Code	Denial Description
N/A	N/A	N/A

Denial Code	Denial Description	Specific “Granular” Denial Findings	Number of Occurrences
N/A	N/A	N/A	N/A

Mississippi Results
A total of three providers were placed on edit in Mississippi. A total of five claims were reviewed, with one of the claims either completely or partially denied. This results in a claim denial rate of 20 percent. The total dollars reviewed was $10,720.84 of which $2,139.91 was denied, resulting in a charge denial rate of 19.96 percent. The top denial reasons were identified based on dollars denied.

Percent of Total Denials	Denial Code	Denial Description
100.00%	5FF2F	No Plan of Care or Certification

Denial Code	Denial Description	Specific “Granular” Denial Findings	Number of Occurrences
5FF2F	No Plan of Care or Certification	Face-to-Face Encounter Requirements Not Met	1

Nebraska Results
A total of one provider was placed on edit in Nebraska. A total of one claim was reviewed, with one of the claims either completely or partially denied. This results in a claim denial rate of 100.00%. The total dollars reviewed was $2,192.69 of which $2,192.69 was denied, resulting in a charge denial rate of 100 percent. The top denial reasons were identified based on dollars denied.

Percent of Total Denials	Denial Code	Denial Description
100.00%	5FNOA	Partial Denial or Full Denial One Reason — No OASIS Assessment Submitted

Denial Code	Denial Description	Specific “Granular” Denial Findings	Number of Occurrences
5FNOA	Partial Denial or Full Denial One Reason — No OASIS Assessment Submitted	No Initial OASIS/OASIS Present for SCIC HIPPS Code	1

New Mexico Results
A total of seven providers were placed on edit in New Mexico. A total of 15 claims were reviewed, with three of the claims either completely or partially denied. This results in a claim denial rate of 20.0 percent. The total dollars reviewed was $40,103.87 of which $9,249.50 was denied, resulting in a charge denial rate of 23.06 percent. The top denial reasons were identified based on dollars denied.

Percent of Total Denials	Denial Code	Denial Description
66.67%	5FF2F	Face-to-Face Encounter Requirements Not Met
33.33%	5TF2F	Face-to-Face Encounter Requirements Not Met

Denial Code	Denial Description	Specific “Granular” Denial Findings	Number of Occurrences
5FF2F	Face-to-Face Encounter Requirements Not Met	Face-to-Face Encounter Requirements Not Met	2
5TF2F	Face-to-Face Encounter Requirements Not Met	Face-to-Face Encounter Requirements Not Met	1

Oklahoma Results
A total of 48 providers were placed on edit in Oklahoma. A total of 80 claims were reviewed, with five of the claims either completely or partially denied. This results in a claim denial rate of 6.25 percent. The total dollars reviewed was $173,545.83 of which $7,555.28 was denied, resulting in a charge denial rate of 4.35 percent. The top denial reasons were identified based on dollars denied.

Percent of Total Denials	Denial Code	Denial Description
60.00%	5F023	No Plan of Care or Certification
20.00%	5CHG3	MR HIPPS Code Change Due to Partial Denial of Therapy
20.00%	5F041	Info Provided Does Not Support the M/N for This Service

Denial Code	Denial Description	Specific “Granular” Denial Findings	Number of Occurrences
5F023	No Plan of Care or Certification	No Plan of Care or Certification	3
5CHG3	MR HIPPS Code Change Due to Partial Denial of Therapy	Medical Review HIPPS Code Change Due to Partial Denial of Therapy	1
5F041	Info Provided Does Not Support the M/N for This Service	The Documentation Submitted Was Insufficient to Support That the Skilled Nurse Service(s) Billed Was or Were Reasonable and Necessary	1

Pennsylvania Results
A total of one provider was placed on edit in Pennsylvania. A total of one claim was reviewed, with 0 of the claims either completely or partially denied. This results in a claim denial rate of 0 percent. The total dollars reviewed was $4,047.86 of which $0.00 was denied, resulting in a charge denial rate of 0 percent. The top denial reasons were identified based on dollars denied.

Percent of Total Denials	Denial Code	Denial Description
N/A	N/A	N/A

Denial Code	Denial Description	Specific “Granular” Denial Findings	Number of Occurrences
N/A	N/A	N/A	N/A

Tennessee Results
A total of 12 providers were placed on edit in Tennessee. A total of 21 claims were reviewed, with three of the claims either completely or partially denied. This results in a claim denial rate of 14.29 percent. The total dollars reviewed was $45,398.43 of which $5,304.22 was denied, resulting in a charge denial rate of 11.68 percent. The top denial reasons were identified based on dollars denied.

Percent of Total Denials	Denial Code	Denial Description
33.33%	5FF2F	Face-to-Face Encounter Requirements Not Met
33.33%	5FNOA	Partial Denial or Full Denial One Reason — No OASIS Assessment Submitted
33.33%	5A301	Info Provided Does Not Support the M/N for Therapy Services

Denial Code	Denial Description	Specific “Granular” Denial Findings	Number of Occurrences
5FF2F	Face-to-Face Encounter Requirements Not Met	Face-to-Face Encounter Requirements Not Met	3
5FNOA	Partial Denial or Full Denial One Reason — No OASIS Assessment Submitted	No Initial OASIS/OASIS Present for SCIC HIPPS Code	1
5A301	Info Provided Does Not Support the M/N for Therapy Services	Skilled Observation Not Needed from Start of Care	1

Denial Reasons and Prevention Recommendations

5FF2F/5TF2F — Face-to-Face Encounter Requirements Not Met

Reason for Denial
The services billed were not covered because the documentation submitted for review did not include (adequate) documentation of a face-to-face encounter.

How to Avoid This Denial
Specific documentation related to face to face encounter requirements must be submitted for review. This includes, but is not limited to, the following:

A face-to-face encounter must occur no more than 90 days prior to the home health start of care date or within 30 days of the start of the home health care;
Encounter was related to the primary reason the patient requires home health services; and
Encounter was performed by a physician or allowed nonphysician practitioner

The certifying physician must also document the date of the face-to-face encounter. The face-to-face encounter can be performed by:

The certifying physician;
The physician who cared for the patient in an acute or post-acute care facility (from which the patient was directly admitted to home health);
A nurse practitioner or a clinical nurse specialist who is working in collaboration with the certifying physician or the acute/post-acute care physician; or
A certified nurse midwife or physician assistant under the supervision of the certifying physician or the acute/post-acute care physician

The certifying physician’s and/or the acute/post-acute care facility’s medical record for the patient must contain the actual clinical note for the face-to-face encounter visit that demonstrates that the encounter:

Occurred within the required timeframe;
Was related to the primary reason the patient requires home health services; and
Was performed by an allowed provider type

This information can be found most often in, but is not limited to the following examples:

Discharge summary;
Progress note;
Progress note and problem list; or
Discharge summary and comprehensive assessment

For more information, refer to:

42 CFR 424.22(a)(1)(v)(A)
42 CFR 424.22(d)(2)
MLN Matters Article SE1436
CMS Manual System, Medicare Benefit Policy Manual Chapter 7, Section 30.5.1.1

5F023/5T023 — No Plan of Care or Certification

Reason for Denial
The services billed were not covered because the home health agency (HHA) did not have the plan of care established and approved by a physician, as required by Medicare, included in the medical records submitted for review and/or the service(s) billed were not covered because the documentation submitted did not include the physician’s signed certification or recertification.

How to Avoid This Denial

Ensure that the appropriate plan of care (POC) is included and that it is legibly signed and dated by the physician prior to billing
A plan of care refers to the medical treatment plan established by the treating physician with the assistance of the home health skilled professional. The plan of care contains all pertinent diagnoses, the patient’s mental status, the types of services, supplies, and equipment required, the frequency of visits to be made, prognosis, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, all medications and treatments, safety measures to protect against injury, instructions for timely discharge or referral and any additional items the HHA or physician chooses to include.
Ensure that the signed certification or recertification is submitted when responding to an ADR

The physician must certify that:
- The home health services were required because the individual was confined to his/her home and needs intermittent skilled nursing care, physical therapy and/or speech-language pathology, or continues to need occupational therapy;
- A plan for furnishing such services to the individual has been established and is periodically reviewed by a physician; and
- The services were furnished while the individual was under the care of a physician
Since the certification is closely associated with the plan of care, the same physician who establishes the plan must also certify to the necessity for home health services. Certifications must be obtained at the time the plan of care is established or as soon thereafter as possible. There is no requirement that a specific form must be used, as long as the intermediary can determine that this requirement is met. When requesting reimbursement for a claim, the provider must have the certification on file and be able to submit this information if medical records are requested by the intermediary.
The physician must recertify at intervals of at least once every 60 days that there is a continuing need for services and should estimate how long services will be needed. The recertification should be obtained at the time the plan of care is reviewed and must be signed by the same physician who signs the plan of care. When requesting reimbursement for a claim, the provider must have the recertification on file and be able to submit this information if medical records are requested by the intermediary.

For more information, refer to:

42 (CFR) Code of Federal Regulations, Sections 424.22 and 409.43.
CMS Internet-Only Manuals (IOMs), Pub 100-02, Medicare Benefit Policy Manual, Chapter 7, Section 30.

42 (CFR) Code of Federal Regulations, Sections 409.41, 409.42, 409.43 and 424.22
CMS Internet-Only Manuals (IOMs), Pub 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4, Section

5FNOA/5ANOA — No Initial OASIS/OASIS Present for SCIC HIPPS Code

Reason for Denial
Medical necessity was not supported as there is no Outcome and Assessment Information Set (OASIS) present in the state repository for the initial HIPPS code billed on the claim.

How to Avoid This Denial
To avoid denials for this reason, the provider should ensure that the OASIS that generated the HIPPS codes on the claim is submitted with the medical records in response to an Additional Development Request (ADR).

Under the Prospective Payment System (PPS), an OASIS is a regulatory requirement. The OASIS that generated the initial HIPPS code is necessary to determine the medical necessity of the level of care billed. Appropriate payment for the entire episode cannot be determined without the OASIS for the initial HIPPS code. As a result, all of the services billed are non-covered.

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

42 (CFR) Code of Federal Regulations, Sections 484.20, 484.55 and 484.250
CMS Manual System, Pub 100-02, Medical Benefit Policy Manual, Chapter 7, Section 10.1, 10.2 and 20.1.2
Outcome and Assessment Information Set Implementation Manual (PDF, 2.8 MB)

5DOW4 — Partial Denial Resulting in a LUPA

Reason for Denial
Based on the medical records submitted for review, a portion of the services provided was denied. This resulted in a Low Utilization Payment Adjustment (LUPA).

A LUPA is an episode with four or fewer visits. The payments are based on the wage adjusted per visit amount for each of the visits rendered instead of the full episode amount.

How to Avoid This Denial
When responding to an Additional Development Request (ADR), ensure the documentation submitted for review supports all criteria for all services billed.

For more information, refer to:

42 (CFR) Code of Federal Regulations, Sections 484.205 and 484.230
CMS Internet-Only Manuals (IOMs), Pub 100-02, Medicare Benefit Policy Manual, Chapter 7, Section 10.7

5CHG3 — Medical Review HIPPS Code Change Due to Partial Denial of Therapy

Reason for Denial
The services billed were paid at a lower payment level. Based on medical review of the records submitted, some of the therapy visits billed were not allowed. Reimbursement was adjusted due to a partial denial of therapy and the original HIPPS code was changed.

How to Avoid This Denial
Under the Prospective Payment System (PPS), Medicare reimbursement rates are based on the patient’s health condition and care needs. In order to receive a higher level of payment based on therapy services, there should be an adequate number of payable therapy visits to meet the threshold. This may include one type of therapy or a combination of occupational, speech-language pathology, or physical therapy services.

Submit orders to cover the therapy visits billed
Submit documentation to support the need for skilled therapy services
Submit all documentation related to the therapy services rendered

For more information, refer to:

Outcome and Assessment Information Set Implementation Manual (PDF, 2.8 MB)
This article can be located on the Palmetto GBA website using the Search feature: CMS Medicare Learning Network (MLN) Matters article #MM7374 – Manual Changes for Therapy Services in Home Health, Publication 100-02, Chapter 7

The Next Steps
The service-specific targeted medical review edits for Home Health Services in Alabama, Arkansas, Arizona, Georgia, Indiana, Kansas, Kentucky, Louisiana, Massachusetts, Michigan, Missouri, Mississippi, Nebraska, New Mexico, Oklahoma, Pennsylvania and Tennessee will be continued based on moderate charge denial rates and medium to high impact severity errors. If significant billing aberrancies are identified, provider-specific review may be initiated.

If you are dissatisfied with a claim determination you have the right to request an appeal. Palmetto GBA encourages you to review the documentation originally submitted, and if you believe you have additional supporting documentation you may include this information with your appeal. For more information related to the appeals process please refer to the “Redetermination: 1st Level Appeal” form (PDF, 232.89 KB).

Questions regarding this medical review can be directed to the Palmetto GBA Provider Contact Center at 855–696–0705.

Postpayment Service-Specific Probe Results for Home Health for October through December 2020

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Postpayment Service-Specific Probe Results for Home Health for October through December 2020

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