The real reason your claim was denied.
Posts from the ‘ADRs’ Category
Every quarter, Palmetto GBA publishes the top reasons for denial and ways to prevent denials on their website. This is their advice about Face-to-Face Encounter documentation which is the second most frequent reason for denial after non-submission of records.
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.
On November 1, I contacted Palmetto GBA through their website. I prefer written responses I can refer to in the future. As a consultant, I find it useful to give clients accurate advice that I can back up with references. That kind of attention to detail gets me paid. Specifically, I wrote:
Please review the information provided under the list of April – June HH Medical Review Top Denial Codes. Your advice states that a narrative is still warranted and says nothing about supplemental documentation. When clicking on the link to ‘General Medical Review’, it provides pre-2015 instructions. And the third link is blog post by Dr. Feliciano with a 2013 date. The first link does go to the current manual but it conflicts with the information you are providing. Since providers are being denied at an alarming rate for F2F, it is abundantly clear that correct information be Provided.
Yesterday marked 47 days after my initial email. I received the following email from Palmetto:
Thank you for your e-mail received on November 01, 2018. You wrote to us regarding F2F information. You indicated there was some conflicting information in the April – June 2018 Home Health Medical Review Top Denial Reason Codes article.
Thank you for your information. We have submitted the information you provided to the Provider Outreach and Education Department for them to review the information provided.
By way of reference, e-mails are answered within 45 business days. Anytime you need immediate assistance, please call us at the telephone number listed below so that a representative can assist you with your questions quickly. You may also use our secure eChat feature that is available on our website at www.PalmettoGBA.com/hhh.
As a Medicare contractor, it is Palmetto GBA’s goal to continuously improve Medicare customer satisfaction through the delivery of high quality and cost-effective customer service. For claim status and eligibility or to speak to a Customer Service Advocate (CSA) about more complex issues, please call 1-855-696-0705. You may also visit the Palmetto GBA eServices to view claim status and eligibility at htps://www.onlineproviderservices.com/ecx_improvev2/. For up to date Medicare news and policy information, please visit our website at http://www.palmettogba.com/Medicare. Medicare beneficiaries should contact 1-800-MEDICARE (1-800-633-4227) for assistance.
I have so many problems with this email that if they were lined up they would reach the moon. Nevermind that. Let’s get you paid.
Know that if you follow the information on Palmetto GBA’s webpage about denials, your claim will be denied because four years ago, the Face-to-Face encounter documentation guidelines changed. The Medicare Benefit Policy Manual, chapter seven, section 220.127.116.11 instructs providers:
As of January 1, 2015, documentation in the certifying physician’s medical records and/or the acute /post-acute care facility’s medical records (if the patient was directly admitted to home health) will be used as the basis upon which patient eligibility for the Medicare home health benefit will be determined.
This does not mean that you may not use a traditional F2F form or attestation statement and the physician can write as much as he or she wants as a narrative, but even if it is perfect, your claim will not payable unless you also submit the physician or hospital documentation. Furthermore, the dates must match. If the physician inadvertently dates the form on the day he signs it instead of the date of the encounter, the documentation will be invalid. The physician names must match, too. If a qualified practitioner other than the certifying physician performs the encounter and prepares the documentation, the certifying physician should sign or initial the documentation to demonstrate that the information was communicated to him or her. (A link to the manual follows this post with complete instructions.)
I see nothing in Palmetto GBA’s instructions about hospital documentation. I see nothing in the coverage manual about a narrative.
I do not feel good about pointing out Palmetto GBA’s lack of response to what I believe to be a legitimate concern on the internet. Then again, I absolutely hate to see claims for excellent care provided by eligible beneficiaries denied because of stupid stuff. When agencies are taught stupid stuff by the contractors responsible for paying their claims, I get angry. Worse is when contractors are contacted and they take 47 days to say they are passing on my question to a different department. It took 47 days to forward an email? All of that kind of negates the claim that Palmetto GBA’s goal is to continuously improve Medicare customer satisfaction through the delivery of high quality and cost-effective customer service. Have Mercy!
For complete instructions regarding the Medicare requirements for documentation of the face-to-face encounter, go to section 30.1 in the coverage manual found at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c07.pdf. If you are new to home health, take a minute and familiarize yourself with sections 20, 30, and 40.
Today’s post is written by John M. Reisinger, CPA (TN Licensed) of Innovative Financial Solutions for Home Health Publisher of the Home Health Care Resource Planner. His contact information follows this post.
John sent the following out in an email this morning so some of you may have already seen it but it is important enough that reading it twice is a good idea. It speaks to a new way that agencies can be denied without a lot of trouble. There are links to supporting information an this needs to be shared with your entire agency.
The CMS Medicare Learning Network (MLN) released a new article on March 24 regarding the denial of payment when a Claim is submitted when there is no (required) corresponding assessment in their system. This will have an effective date of April 1, 2017; so this is something that you want all your billers to be on top of, as well as those that manage the OASIS submission process. (Julianne’s note: often the OASIS is submitted but not included with ADR information when a recertification falls in the prior episode. Be sure that the person compiling the ADR knows to go back and retrieve the recert OASIS.)
PROVIDER TYPE AFFECTED
This MLN Matters Article is intended for Home Health Agencies (HHAs) submitting claims to Medicare Administrative Contractors (MACs) for home health services provided to Medicare beneficiaries.
PROVIDER ACTION NEEDED
In Change Request (CR) 9585, the Centers for Medicare & Medicaid Services (CMS) directed MACs to automate the denial of Home Health Prospective Payment System (HH PPS) claims when the condition of payment for submitting patient assessment data has not been met. CR9585 is effective on April 1, 2017. This article is a reminder of the upcoming change and provides further information to assist HHAs in avoiding problems with these Medicare requirements. Make sure that your billing staffs are aware of this change.
Don’t cost yourself money by not paying attention to the details. This has always been a requirement under PPS, just a loosely (if at all) enforced regulation. That is changing effective April 1st. Now is not the time to worry about the ‘way we have always done it’, now is the time to start doing it ‘the way it should be done’. Hopefully your software has systems in place to identify these instances when they occur, and your billers have an understanding of how to verify what is appropriate to be billed and what is not yet ready and why (and have processes in place to share that information with you immediately).
In fact, everyone should now be moving to and focusing on ‘the way it should be done’ in all aspects of their operations instead of the‘way we have always done it’, because if things we did in the past were so good, we wouldn’t be having the troubling relationship that we currently have with CMS, MedPac, Congress, et al, that we do have.
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The following is from a denial a client sent last week. The clinical record was originally requested as a routine ADR and payment was denied related to the Face-to-Face document. That denial was overturned in favor of my client but the claim was denied again for a new reason. You have to see this in order to believe it:
Documentation submitted by the provider included a valid face to face encounter form that supported the beneficiary’s skilled need and homebound status. The submitted documentation further suppo1ted skilled nursing services to be reasonable and necessary as evidenced by documentation supported an acute functional and mental decline, recent hospitalization and the need for assessment and observation of condition. However, in review of the physical therapy and occupational therapy evaluations it has been determined the evaluations failed to include short term and long term goals stated in measurable terms with expected dates of accomplishment. Therefore, the six physical therapy visits and the six occupational therapy visits rendered as billed from March 25 to April 12, 2013 will be denied due to invalid/incomplete evaluations.
So, what we end up with a patient that everyone agrees needed services, met Medicare’s eligibility requirements and the agency received no payment because of failure to state long and short term goals.
Did you happen to notice that the entire course of therapy was three weeks?
Have you figured out yet that there were no long/short term goals differentiated on the original chart submitted? That really gets under my skin.
In essence, the denial related to a Face-to-Face document should have never occurred but it did in spite of a perfectly fine document. They agency lost a full round of appeals before the reviewers found something else wrong with the chart. Now the agency is going to the QIC with what amounts to a first round appeal for the PT goals that were never mentioned in the first denial.This example stood out because the reviewer actually wrote that all other requirements were met. I don’t know why she felt compelled to point out how very much the patient’s need for services was supported and payment would have been made save for lack of a long or short term goal. In actuality, there were five of these I worked last week.
You have two choices. First, you can write a short term goal or you can write a very long term goal. The problem with a long term goal is the ability to assess progress towards goals after the patient is discharged. I supposed you could set a goal of swimming the English Channel because I think there is a published list of all who have successfully crossed. Outside of publically available information, how would you verify completion of the goal without violating HIPAA rules?
An alternative solution would be to write a goal or two for the first visit or first week of therapy. Some examples that come to mind from who knows where because I am not a therapist are:
- The patient will agree to participate in their course of therapy by the end of the first visit. (Chances are this is pretty accurate if the patient allows you in for a second visit).
- The patient will have all prescriptions for pain filled prior to next visit. (I do not like the way it sounds when therapists work with un-medicated patients.)
- The patient will have DME delivered by end of day 4 of episode. (If nothing else, this will serve as a reminder to follow up and ensure that DME was delivered.
I have shared this information with several clients who think I have loaned my brain out to someone who needed a laugh. I assure you that is not the case. All of you who receive a denial such as the one described above should include in your argument for payment that whatever new deficiency was identified after the initial denial was overturned was also present in the original submission of documentation. Be bold about it. Include page numbers.
I would be interested to hear what is happening in your offices. Has anyone else seen denials like these? If so, what contractor? (Palmetto, NGS, CGS, etc.) Email me if you don’t want your denials plastered all over the internet or better yet, be loud about them and post them below.