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The Real Reason your Claim was Denied


A good mystery is a delight but they should be reserved for leisure time reading. It should not be an element of Requests for Additional Information (ADRs) from Palmetto GBA or any other Medicare contractor. And yet, they are. Below are some examples that have come across my desk in recent months as the Targeted Probe and Educate (TPE) process marches forward. I admit that at times I am truly challenged.

There are two denial codes in particular that keep showing up and really, they could mean anything. The first is:

5F023 – No Plan of Care or Certification

Believe it not, there are some people who think this means that no plan of care or certification was included with the submission of documents. If it is found when the biller is checking claims status, he or she may simply fax over the plan of care thinking they are helping the agency get paid faster. There goes one round of appeals.

If they had taken the time to look up this reason for denial on Palmetto GBA’s website they may have found an explanation that confirmed their initial impression. It is prefaced by the following:

The services billed were not covered because the home health agency (HHA) did not have the plan of care (POC) 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.

So, when a letter arrives in the mail two days after the resubmission of the plan of care, agencies may be surprised to find out their claim was denied because the physician’s Face-to-Face encounter did not support homebound status in his clinic note. Maybe because it is not a requirement for their patients to be homebound so they don’t think about it.

You would think they would make a code just for homebound status so that the reason codes for denials would correspond with the reasons for denial. That’s what I would do.

To be fair, nobody is doubting homebound status. Rather, they are saying that the physician did not fully support homebound status.

Another claim denied for having no certification or plan of care was explained the same way. The Face-to-Face encounter documentation did not support homebound status. The physician documented that the beneficiary was having recurrent dizziness, continued incisional pain, low back pain and bilateral knee pain. The medication list included percocet, alprazolam and hydroxyzine. And yet, a reviewer at Palmetto does not understand how dizziness, knee pain, back pain and incisional pain might reduce the ability of a patient to leave the home and tolerate the outing with aplomb.

5FF2F – The physician certification was invalid because the required face‐to‐face encounter was missing/incomplete/untimely.

As an additional bonus, there is no shortage of claims denied for reason code 5FF2F – The physician certification was invalid because the required face‐to‐face encounter was missing/incomplete/untimely.

So which is it? Is the Face-to-Face missing or untimely or incomplete? Responding to a denial is not the time for guesswork.

On one appeal, Palmetto GBA asserted:

… The face to face encounter note indicated that the beneficiary required the use of a wheelchair, thus satisfying criterion one of the face to face requirements. However, criterion two was not met. There was no indication of a normal inability to leave the home or how leaving the home would require a considerable or taxing effort.

The physician wrote in the encounter documentation that the patient had a catheter, a prior CVA, dilated cardiomyopathy and he ordered a hospital bed and an alternating pressure mattress for the prevention of skin breakdown.  An overnight pulse oximetry was ordered to determine if the patient qualified for supplemental oxygen. There was a previous stroke resulting in weakness and difficulty with speech. Could anyone (in their 90’s) have this combination of conditions and find it NOT taxing to leave home?

The physician does not follow the patient home and determine how the patient tolerated the outing.  He or she doesn’t call the patient in the morning like the dentist who performed a root canal.  

In all of the denial letters, the Medicare Benefit Policy Manual, Chapter 7, is referenced.  Section 30.5.1.2 of that manual states:

The certifying physician and/or the acute/post-acute care facility medical record (if the patient was directly admitted to home health) for the patient must contain information that justifies the referral for Medicare home health services. This includes documentation that substantiates the patient’s: 

Need for the skilled services; and 
Homebound status; 

The key word here is ‘substantiate’.  According to the Manual, the physician does not need to document specifically how the patient tolerated the outing from home.  Rather, there must be sufficient information to substantiate that a patient can not leave home without a considerable or taxing effort. 

Don’t get angry.  I’m mad enough for us all and it isn’t healthy.

Call a consultant if you need help.  (My number, 225-253-4876, is a good start.)

Meanwhile, I’m trying to figure out how they will handle Medical Review in PDGM.  Could it be we get a break the way we did when PPS was first implemented?

Questions and comments are always welcome.  Look for the comments section or email me at your convenience.


a 365 day a year thing


A really good thing about being busy around the Christmas holidays is that there isn’t a lot of time to spend at Wal-Mart or watching TV viewing Madison Avenue’s idea of the perfect Christmas.  If you work as a home health or hospice nurse, you know how most of America lives and there is a reason they don’t make TV commercials promoting conspicuous spending aimed towards our patients.

When my son was ten, I was working at the cath lab.  He had the worst case of chicken pox I have ever seen outside of the ICU.  It was amazing to see how fast those little pox appeared.  The cath lab where I worked was owned by three groups of physicians.  Each of those groups had a Christmas party that year and of course, the cath lab had their own party.  That was four.  Four dresses, four pairs of shoes, four parties with essentially the same attendees.

Then there were some family obligations, the shopping, the cooking and all the relatives coming into town for Christmas.  I  also had to squeeze in about 8 or 10 hours of work every day because everyone wanted their heart cath done by the end of the year because their deductible had already been paid.

But, the cath lab was closed on Christmas.  I finally got the day off.  I overslept,was too cranky to enjoy my family and felt put upon to stay awake and visit with my favorite people in the world.

This is what I learned that year and it has stayed with me ever since unlike a lot of life’s lessons that I promptly forget.

  1. People are sick 365 days a year.  It is not a coincidence that we are nurses for an equal number of days.
  2. People do not always consider your schedule when they die or get sick.
  3. A party is a party.  Nobody dies if you decline an invitation.
  4. You do not have to wait until Christmas to spend time with your family
  5. Your best friend deserves a present any time you think about it and overlooks it if you don’t kill yourself trying to find the perfect sweater on Christmas eve.
  6. When you are feeling grumpy, fat, unloved and unwanted, visit a nursing home.  You will see how valuable you are at your worst.
  7. The holidays coincide with the flu season.  Take care of yourself.
  8. If you have to choose between spending some time with your 8 yr old or making a sweet potato casserole, buy the casserole.
  9. Gifts from the heart are not found on aisle 7.  Competitive gift giving is a game for the morally vacant.
  10. Christmas inspires charity.  The soup kitchens, homeless shelters, etc. are open all year.  Sometimes you’re needed most on a random Wednesday in August.

I wish you all the very best for Christmas.  I hope that the peace and good will you find are lasting.  My life is better because of you.  More importantly, there are a lot of elderly folks living at home comfortably surrounded by their families because of you.  Someone without a family feels less alone this holiday season because of you and you are going to be there next week for those patients who were disappointed when their children couldn’t find the time to visit.  Some of you who are not working will sneak away from the fam and run a plate by a patient you know will be alone.  I know you.  Take your kids.

If you have to work Christmas day, be there for your patients because the example you are setting for your family is more valuable than a new Xbox. The fabric of your family is built upon your continual presence, physical and emotional.  You are not a Mom, a Wife, a husband, a child or Best Friend on holidays only.  Like nursing, its a 365 day kind of thing.

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