1. Medical Review and Appeals Top Denials
Provider Outreach & Education Advisory Group J6 Home Health October 18, 2017
Medical Review and Appeals Top Denials

2. Medical Review – Top Denials
55HTW = The physician certification was invalid since the required face-to-face encounter was missing/incomplete/untimely.
55H4D = The medical documentation submitted did not show that the therapy services were reasonable and necessary and at a level of complexity which requires the skills of a therapist.
56900= The requested medical records were not received with the 45 day time limit.

3. Avoiding Denials for 55HTW
Denial Code 55HTW - Face to Face Encounters -The physician certification was invalid since the required face-to-face encounter was missing/incomplete/untimely. Ensure there is documentation (a physician or allowed NPP clinical note) in the medical record that demonstrates that a face-to-face encounter has occurred within the required timeframe.
For episodes with starts of care beginning January 1, 2011 and later, in accordance with § below, a face-to-face encounter occurred no more than 90 days prior to or within 30 days after the start of the home health care, was related to the primary reason the patient requires home health services, and was performed by an allowed provider type. The certifying physician must also document the date of the encounter.
Available Education:
Job Aids - Face-to-Face Encounters 2016, HH Mock Chart Checklist Suggestions
Webinars – HH Face-to-Face Encounter and the Plan of Care, Ordering & Certifying Medicare HH Services
Medicare University CBT - Face-to-face Encounters and the Plan of Care

4. Avoiding Denials for 55H4D
Denial Code 55H4D – The medical documentation submitted did not show that the therapy services were reasonable and necessary and at a level of complexity which requires the skills of a therapist.
For any home health services to be covered by Medicare, the patient must meet the qualifying criteria as specified in §30, including having a need for skilled nursing care on an intermittent basis, physical therapy, speech-language pathology services, or a continuing need for occupational therapy as defined in this section.
Available Education:
Job Aid - Documentation to Support the Initial and Continued Need for Skilled Home Health Services, Billing G-Codes for Therapy and Skilled Nursing Services
Webinars – Ordering & Certifying Medicare HH Services
Medicare University CBT - Home Health Homebound Status & the Need for Skilled Services

5. Avoiding Denials for 56900
Denial Code 56900– The requested medical records were not received with the 45 day time limit.
During the review process, if the provider fails to respond to a Medicare contractor’s Additional Documentation Request (ADR) within the prescribed time frame, the Medicare contractor shall deny the claim. See Pub , Medicare Program Integrity Manual, chapter 3, section for information on denials based on non-response to ADRs and section for handling of late documentation.
Available Education:
Job Aids – HH ADR Mock Chart Check List Suggestions
Webinars – HH Documentation and the Additional Development Request
Live Events –Annual CAHSAH Event “Is ADR on Your Radar?”
Medicare University CBT - HH Documentation and the Additional Development Request

6. Appeals – Top Denials
37253 = The claim receipt date is more than 40 days after the OASIS assessment completion date returned from QIES.
55H2B = Documentation submitted does not support homebound status
55HTW = The physician certification was invalid since the required face-to-face encounter was missing/incomplete/untimely

7. Avoiding Denials for 37253
Denial Code: The claim receipt date is more than 40 days after the OASIS assessment completion date returned from QIES.
OASIS reporting regulations require the OASIS to be transmitted within 30 days of completion (+10 days during transitional time). Before submitting an HH claim to your MAC, the HHA should ensure the OASIS assessment has completed processing and was successfully accepted into the QIES National Database. For the claim to be denied, the assessment must be both missing AND past due.
Available Education:
Job Aids –OASIS Requirements, Billing the HH Final Episode Claim, Coding HH Episodes that span October 1, 2015,
Webinars – HH Certification and Recertification, Ordering & Certifying Medicare HH Services, Home Health Billing Basics
MLN Matters Number SE17009 released 3/24/17 - “Denial of Home Health Payments When Required Patient Assessment Is Not Received – Additional Information”

8. Avoiding Denials for 55H2B
Denial Code: 55H2B – Homebound Status
The Homebound status is not justified by the documentation in the certifying physician’s and/or the acute/post-acute care facility records. Examples of documentation to support homebound status may include: facility therapy notes, social work or discharge planning records, history and physicals, and other clinical progress notes.
Available Education:
Job Aids – HH Eligibility Criteria and Homebound Status, HH Mock Chart Checklist Suggestions
Webinars – HH Homebound Status & the Need for Skilled Services, Ordering & Certifying Medicare HH Services
Medicare University CBT - Homebound Status & the Need for Skilled Services

9. Avoiding Denials for 55HTW
Denial Code 55HTW - Face to Face Encounters
The physician certification was invalid since the required face-to-face encounter was missing/incomplete/untimely. Ensure there is documentation (a clinical note) in the medical record that demonstrates that a face-to-face encounter has occurred within the required timeframe.
Available Education:
Job Aid - Face-to-Face Encounters 2016, HH Mock Chart Checklist Suggestions
Webinars – HH Face-to-Face Encounter and the Plan of Care, Ordering & Certifying Medicare HH Services
Medicare University CBT - Face-to-face Encounters and the Plan of Care

10. Thank You
References:
CMS IOM Publication , Medicare Benefit Policy Manual, Chapter 7
CMS IOM Publication , Medicare Claims Processing Manual, Chapter 10
CMS IOM Publication , Medicare Program Integrity Manual, Chapter 6
Manual Updates to Clarify Requirements for Physician Certification and Recertification of Patient Eligibility for Home Health Services”
MLN/MLNMattersArticles/Downloads/MM9119.pdf
In accordance with its references to Transmittal 92 & 208 in the CMS IOM Publications and