Palmetto GBA: HIPPS Codes 2CGK* & 1BGP* in Four Regions Medical Review Results

The J11 Medical Review Department performed a service-specific prepay targeted medical review on claims for 2CGK* and 1BGP* (variable last digit of HIPPS codes). These edits were set for four regions within the J11 Home Health jurisdiction:

  • Midwest (including IL, IN and OH)
  • Southeast (KY, NC, SC and TN)
  • Southwest (AR, LA, NM, OK and TX)
  • Gulf Coast (AL, FL, GA and MS).

These results are for claims processed February through April 2013.

2CGK* – Gulf Coast Results: Of the four claims reviewed, two were either completely or partially denied, resulting in a claim denial rate of 50 percent. A total of $6,981.55 charges was reviewed with $4,707.66 denied, resulting in a charge denial rate of 67.4 percent. The major denial reasons identified were:

Percent of Total Denials Denial
Code
Denial Description
52.1%
5FF2F
Face to Face Encounter Requirements Not Met
47.9%
56900
Requested Medical Records Not Submitted Timely

2CGK* – Midwest Results: Of the 12 claims reviewed, five were either completely or partially denied, resulting in a claim denial rate of 41.7 percent. A total of $22,653.09 charges was reviewed with $9,964.88 denied, resulting in a charge denial rate of 44 percent. The major denial reasons identified were:

Percent of Total Denials
Denial Code
Denial Description
25.2%
5FF2F
Face to Face Encounter Requirements Not Met
25.2%
5A041
Info Provided Does Not Support Medical Necessity for This Service
25.2%
56900
Requested Medical Records Not Submitted Timely
22.2%
5FNOA
Appropriate OASIS Not Submitted

2CGK* – Southeast Results
Of the two claims reviewed, with charges of $2,507.46, zero were either completely or partially denied, resulting in a claim denial rate and a charge denial rate of zero percent.

2CGK* – Southwest Results
Of the 19 claims reviewed, six were either completely or partially denied, resulting in a claim denial rate of 31.6 percent. A total of $26,446.93 charges was reviewed with $11,562.44 denied, resulting in a charge denial rate of 43.7 percent. The major denial reasons identified were:

Percent of Total Denials
Denial Code
Denial Description
60.3%
5FF2F
Face to Face Encounter Requirements Not Met
20.7%
5F013
Physician’s Plan of Care and/or Certification Present – Signed but Dated Untimely
19.1%
56900
Requested Medical Records Not Submitted Timely

1BGP* – Midwest Results: Of the 356 claims reviewed, 122 were either completely or partially denied, resulting in a claim denial rate of 34.3 percent. A total of $1,192,265.80 charges was reviewed with $336,942.86 denied, resulting in a charge denial rate of 28.3 percent. The major denial reasons identified were:

Percent of Total Denials
Denial Code
Denial Description
49.9%
5FF2F
Face to Face Encounter Requirements Not Met
19.4%
56900
Requested Medical Records Not Submitted Timely
6.0%
5FNOA
Appropriate OASIS Not Submitted
5.8%
5F011
Physician’s Plan of Care and/or Certification Present – No Signature
1BGP* – Southeast Results: Of the 311 claims reviewed, 85 were either completely or partially denied, resulting in a claim denial rate of 27.3 percent. A total of $962,671.01 was reviewed with $240,519.89 denied, resulting in a charge denial rate of 25 percent. The major denial reasons identified were:
Percent of Total Denials
Denial Code
Denial Description
45.2%
5FF2F
Face to Face Encounter Requirements Not Met
20.5%
56900
Requested Medical Records Not Submitted Timely
8.2%
5FNOA
Appropriate OASIS Not Submitted
6.7%
5F011
Physician’s Plan of Care and/or Certification Present – No Signature
5.8%
5F012
Physician’s Plan of Care and/or Certification Present – Signed but Not Dated

1BGP* – Southwest Results: Of the 404 claims reviewed, 119 were either completely or partially denied, resulting in a claim denial rate of 29.5 percent. A total of $1,297,204.64 charges was reviewed with $322,719.47 denied, resulting in a charge denial rate of 24.9 percent. The major denial reasons identified were:

Percent of Total Denials
Denial Code
Denial Description
33.1%
56900
Requested Medical Records Not Submitted Timely Services Not Documented
31.6%
5FF2F
Face to Face Encounter Requirements Not Met
9.3%
5F012
Physician’s Plan of Care and/or Certification Present – Signed but Not Dated
4.7%
5F011
Physician’s Plan of Care and/or Certification Present – No Signature

1BGP* – Gulf Coast Results: Of the 609 claims reviewed, 157 were either completely or partially denied, resulting in a claim denial rate of 25.8 percent. A total of $1,989,174.66 charges was reviewed with $436,508.93 denied, resulting in a charge denial rate of 21.9 percent. The major denial reasons identified were:

Percent of Total Denials
Denial Code
Denial Description
29.4%
5FF2F
Face to Face Encounter Requirements Not Met
27.6%
56900
Requested Medical Records Not Submitted Timely Services Not Documented
11.1%
5FNOA
Appropriate OASIS Not Submitted
10.8%
5F012
Physician’s Plan of Care and/or Certification Present – Signed but Not Dated

Denial Reasons and Prevention Recommendations

5FF2F/5TF2F-Face-to-Face Encounter Requirements Not Met: The services billed were not covered because the documentation submitted for review did not include (adequate) documentation of a face-to-face encounter.

To avoid a denial, the face-to-face encounter must occur no more than 90 days prior to the home health start of care date or within 30 days after the start of care. Specific documentation related to face to face encounter requirements must be submitted for review. This includes, but is not limited to, the following:

  • The certifying physician must document that he/she or an allowed non-physician practitioner (NPP) had a face-to-face encounter with the patient, including the date of the encounter
  • The documentation of the encounter must include a brief narrative, composed by the certifying physician, describing how the patient’s clinical condition as observed during that encounter supports the patient’s homebound status and need for skilled services
  • The certifying physician must document the encounter either on the certification, which the physician signs and dates, or on a signed addendum to the certification
  • The certifying physician may dictate the face-to-face encounter documentation content to one of the physician’s support personnel to type. The documentation may also be generated from a physician’s electronic health record.

For more information, refer to:

  • CMS Manual System, Medicare Benefit Policy Manual Chapter 7, Section 30.5.1.1

56900 – Requested Medical Records Not Submitted Timely: The services billed were not covered because the claim was not submitted or not submitted timely in response to an Additional Development Request (ADR). When an ADR is generated, the provider has 30 days from the date the ADR was generated to respond with medical records. In accordance with CMS instructions, if the documentation needed to make a medical review determination is not received within 45 days from the date of the documentation request, Palmetto GBA will make a medical review determination based on the available medical documentation. If the claim is denied, payment will be denied or an overpayment will be collected.

Tips to Prevent the Denial of Claims for Untimely Response to ADRs:

  • Be aware of the ADR date and the need to submit medical records within 30 days of the ADR date
  • Submit the medical records as soon as the ADR is received
  • Monitor the status of your claims in Direct Data Entry (DDE) and begin gathering the medical records as soon as the claim goes to the location of SB6001
  • Return the medical records to the address on the ADR. Be sure to include the appropriate mail code or station number. This ensures that your responses are promptly routed to the Medical Review Department.
  • Gather all of the information needed for the claim and submit it all at one time
  • Attach a copy of the ADR request to each individual claim
  • If responding to multiple ADRs, separate each response and attach a copy of the ADR to each individual set of medical records. Make sure each set of medical records is bound securely with one staple in the upper left corner or a rubber band to ensure that no documentation is detached or lost. Do not use paper clips.
  • Do not mail packages C.O.D.; we cannot accept them

For more information, refer to the following article on the Palmetto GBA J11 Part A website: Medical Review Progressive Corrective Action (PCA) Process

5ANOA/5FNOA – Unable to Determine Medical Necessity of HIPPS Code Billed as Appropriate OASIS Not Submitted: The services billed were not covered because the home health agency did not submit the Outcome and Assessment Information Set (OASIS) for the HIPPS code billed on the claim. To avoid denials for this reason, the provider should ensure that the OASIS that generated the HIPPS code for 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. If the home health agency does not submit the OASIS, the medical reviewer cannot determine the medical necessity of the level of care billed and no Medicare payment can be made for those services.

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

5F012/5T012 – Physician’s Plan of Care and/or Certification Present – Signed but Not Dated: The service(s) billed (was/were) not covered because the physician signed but did not date the plan of care and certification prior to billing Medicare.
In order to avoid unnecessary denials for this reason, the provider should verify that the physician has dated his/her signature.

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
  • 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 further information on the above Medicare coverage issue regarding the plan of care, references include, but are not limited to, these resources:

  • 42(CFR) Code of Federal Regulations, Sections 424.22 and 409.43
  • CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Chapter 7, Section 30
  • Article ‘Date Stamps No Longer Accepted: Physicians Must Date Signatures ’ located on our website

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

  • 42 (CFR) Code of Federal Regulations, Sections 409.41, 409.42, 409.43 and 424.22
  • CMS Manual System, Pub 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4, Section 30
  • Article ‘Date Stamps No Longer Accepted: Physicians Must Date Signatures ’ located on our website

5A041/5F041 – Information Provided Does Not Support the Medical Necessity for This Service: The skilled nursing visit(s) (was/were) not covered because the documentation submitted in response to the Additional Development Request did not support medical necessity for continuation of skilled services.Initially skilled nursing services were required to observe and assess the beneficiary’s medical condition and response to the plan of care.  The key to Medicare coverage is for the documentation to “paint a picture” of the beneficiary’s overall medical condition indicating the need for skilled service.

Skilled observation and assessment beyond a three-week period may be justified when documentation supports the likelihood of further complications or an acute episode.  However, observation and assessment are not reasonable and necessary when the documentation indicated that the abnormal findings are part of a longstanding pattern of the patient’s condition and there is no attempt to change the treatment to resolve them.

Documentation that may be helpful to avoid future denials for this reason may include, but is not limited to, the following:

  • New and/or changed prescription medications
  • ‘New’ medications are those that the patient has not taken recently, i.e. within the last 30 days
  • ‘Changed’ medications are those that have a change in dosage, frequency or route of administration within the last 60 days
  • New onset or acute exacerbation of diagnosis
  • Hospitalizations (include the date and reason)
  • Acute change in condition
  • Changes in treatment plan as a result of changes in condition (e.g. physician’s contact, medication changes)
  • Changes in caregiver status
  • Complicating factors (e.g. simple wound care on lower extremity for a patient with diabetes)
  • Inherent complexity of services that causes them to be safely and effectively provided only by skilled professionals

In addition, the skilled nursing visits for teaching and training activities are reasonable and necessary where teaching or training is appropriate to the patient’s functional loss, illness, or injury. Teaching and training for an appropriate period of time may be medically necessary when the documentation reflects why the teaching and training is required. When it becomes apparent after a reasonable period of time that the patient, family or caregiver will not or is not able to be trained, then further teaching and training would cease to be reasonable and necessary.

To avoid future denials for this reason, documentation should reflect a need for one or more of the following:

  • Initial teaching and training of a patient, a patient’s family or caregiver on how to manage the patient’s treatment regime
  • Reinforcement of previous teaching when there is a change in physical location (e.g. discharged from hospital to home)
  • Re-teaching due to a significant change in a procedure, the patient’s condition or the patient’s caregiver is not properly carrying out the task
  • Other reasons that may require skilled teaching and training activities

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

  • 42 (CFR) Code of Federal Regulations, Sections 409.32, 409.33 and 409.44
  • CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Chapter 7, Sections 40.1.2.1 and 40.1.2.3

5F013/5T013 – Physician’s Plan of Care and/or Certification Present – Signed but Dated Untimely: The service(s) billed (was/were) not covered because the physician either signed the plan of care after the claim was billed or did not date his/her signature on the plan of care. In order to avoid unnecessary denials for this reason, the provider should verify that the physician has dated his/her signature prior to billing the claim to Medicare.
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 424.22 and 409.43
  • CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Chapter 7, Section 30
  • Article ‘Date Stamps No Longer Accepted: Physicians Must Date Signatures ’ located on our website

Also, the service(s) billed (was/were) not covered because the physician signed the Home Health Certification and Plan of Care after the claim was billed or did not date his/her signature on the Home Health Certification and Plan of Care.

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
  • The services are or 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 further information on the above Medicare coverage issue, references include, but are not limited to, these resources:

  • 42 (CFR) Code of Federal Regulations, Sections 409.41, 409.42, 409.43 and 424.22
  • CMS Manual System, Pub 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4, Section 30

5F011/5T011 – Certification Not Signed: The service(s) billed (was/were) not covered because the physician did not ‘sign’ the plan of care prior to billing Medicare.

In order to avoid unnecessary denials for this reason, the provider should ensure that the attending physician has signed and dated the plan of care prior to the claim being submitted for payment. The form may be signed by another physician who is authorized by the attending physician to care for his/her patients in his/her absence. Electronic signatures are acceptable if entries are appropriately authenticated and dated. Authentication must include signatures, written initials, or computer secure entry by a unique identifier of a primary author who has reviewed and approved the entry. The home health agency must have safeguards to prevent unauthorized access to the records and a process for reconstruction of the records upon request from the intermediary, state surveyor, or other authorized personnel or in the event of a system breakdown.

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 424.22 and 409.43
  • CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Chapter 7, Section 30
  • CMS Manual System, Pub 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4, Section 30
  • Article ‘Date Stamps No Longer Accepted: Physicians Must Date Signatures ’ located on our website

Also, the service(s) billed (was/were) not covered because the documentation submitted did not include the physician’s signed certification/recertification. To avoid denials for this reason, ensure that the attending physician has signed and dated the certification/recertification.

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

  • 42 (CFR) Code of Federal Regulations, Sections 409.41, 409.42, 409.43 and 424.22
  • CMS Manual System, Pub 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4, Section 30
  • Article ‘Date Stamps No Longer Accepted: Physicians Must Date Signatures ’ located on our website

Next Steps

All of the service-specific HIPPS code edits will be continued at the targeted medical review level. The HIPPS code 2CGK* has been identified as a major risk area for J11, and the edits in the Midwest, Southwest and Gulf Coast regions all had a  charge denial rate greater than 33 percent. Although there were no denials for HIPPS code 2CGK* in the Southeast region, the sample size consisted of only two claims, which is insufficient volume to determine whether there is a problem with this code in this region. Therefore the Southeast edit, as well as the other three with the high charge denial rates will be continued. If significant billing aberrancies are identified, provider-specific medical review may be initiated.

The HIPPS code 1BGP* has been identified as a moderate risk area for J11, and the charge denial rates and claim denial rates for all four edits are near and/or below 33 percent. However, due to the medium impact and severity of errors identified, as well as the significant amount of denied dollars, all four of the edits for HIPPS code 1BGP* will be continued. If significant billing aberrancies are identified, provider-specific medical review may be initiated.

Questions regarding the Home Health HIPPS codes reviews can be directed to the Provider Contact Center (866) 830-3925.

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