The 5 Most Common Medical Review Denials & How to Avoid Them

Home health agencies are being hit with medical reviews from all Centers for Medicare & Medicaid Services (CMS) contractors. There is much to be learned from the last few years of medical review results, regardless of the review contractor. Home health medical review denials are repeatedly the same—and not just from one contractor to another, but year after year.   

Listed below are the top five denials that are commonly experienced throughout home health, regardless of contractor or where the agency is located, as well as tips to help your agency avoid these denials.

1. The initial certification was missing, incomplete or invalid, so the recertification episode is denied.

• The initial certification requirements were not met at the start of care (SOC), so, all subsequent episodes under review were denied.
• The recertification documentation does not support medical necessity or the homebound status. The clinician repeated the patient’s history and physical examination information from the SOC and found the outcome and assessment information set (OASIS) documentation did not support ongoing skilled needs.  

Tips to avoid this denial: While every certification period stands alone, the initial certification of the patient is critical, due to the face-to-face (F2F) encounter requirement only applying to the initial certification. All certification requirements must be met for all subsequent recertifications to be covered. Note that many receive this denial due to failing to submit the original SOC plan of care and F2F documents to the medical reviewers when a subsequent period is requested for review. Finally, there are five points of certification, and each one must be met to ensure full certification requirements.  

These five elements must be attested to or acknowledged by the certifying physician or allowable provider for the initial certification:

• The patient is confined to their home.
• The patient needs intermittent skilled nursing, physical therapy or speech-language pathology services. 
• The patient is under the care of a physician or allowable provider.
• The plan of care has been established and is periodically reviewed by a physician or allowable provider.
• An F2F 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.

2. The physician certification was invalid since the required F2F encounter was missing, incomplete or untimely (F2F requirements not met).

• The point of care or other supplemental addendum did not attest to the F2F encounter date or to the correct date. 
• The encounter note was not signed and dated by the physician or the nonphysician practitioner.
• The F2F encounter was not related to the primary diagnosis or primary reason for home health services.
• The F2F encounter was performed by another community physician and not the certifying physician. The agency used an F2F encounter progress note that was not from the certifying physician, or a physician that cared for the patient in the acute or post-acute facility from which the patient was directly referred to home health.

Tips to avoid this denial:  Noncompliance with F2F requirements has been in the top five denial reasons since the inception of F2F requirements in 2011. Many agencies have failed to ensure that they have an F2F document that meets requirements from the beginning of an admission to home health.  

A checklist to follow when reviewing the F2F requirements includes:

• Did the encounter occur within 90 days prior or 30 days after the SOC date?
• Was the encounter conducted by an allowable practitioner?
• Did the primary diagnosis or reason for homecare get treated or addressed during the encounter?
• Is the encounter signed and dated by said allowed practitioner?

3. Skilled nursing services were not medically necessary.  

• The documentation failed to support a skilled service that was provided at the visit. The documentation contained generalized instruction and/or was repetitive without an explanation of why repetitive teaching was required, such as a new caregiver.
• Frequency orders were not updated or written for the change in frequency. The visits provided were not ordered or exceeded the physician’s orders.
• It is the home health agency’s responsibility to provide clear documentation of the medical necessity and reasonableness. This includes progress or lack of progress, medical condition, functional losses and treatment goals.

Tips to avoid this denial: When documenting medical necessity, identify the skilled service and the reason the skilled service is necessary for the beneficiary. Instructions should be clearly documented, and if repetitive teaching is required, the documentation should support why and to whom it was given.  

Some key elements to support medical necessity in documentation include:

• Changes in caregiver status or an unstable caregiving situation
• Complicating factors
• Inherent complexity of services
• Lack of knowledge or understanding of the beneficiary’s care, which requires initial skilled teaching and training of a beneficiary, the beneficiary’s family or a caregiver 
• Reinforcement of previous teaching when there is a change in the beneficiary’s physical location
• Any type of reteaching due to a significant change in a procedure, the beneficiary’s medical condition or when the beneficiary’s caregiver is not properly carrying out the task

4. The medical documentation submitted did not show the therapy services were reasonable, necessary or at a level of complexity that requires a therapist’s skills.  

• The prior level of function was not documented at the evaluation time to support a functional decline for restorative therapy.
• Most often, the therapist documents what the patient did in general terms and doesn’t document what the therapist did, such as verbal cues, type of assistance, number of repetitions, rest breaks required or how the patient tolerated the treatment.
• The documentation did not support the medical necessity of all skilled therapy visits provided. With a home exercise program that can be established, and documented and that patient and caregiver both understand and complete, further continued progression does not require the skill of a therapist.
• Services involving activities for the general welfare of any patient—such as general exercises to promote overall fitness or flexibility, activities to provide diversion or general motivation—do not constitute skilled therapy.

Tips to avoid this denial: To determine whether a service is reasonable and necessary, the Medicare reviewers consider each beneficiary’s unique medical condition. The medical record documentation, including plan of care and OASIS, provide the basis for this determination. Coverage decisions are based upon the objective clinical evidence of the beneficiary’s individual need for skilled care. It is the home health agency’s responsibility to provide clear documentation of the medical necessity for therapy. Therapy does require short and long-term goals.

A checklist for reviewing therapy visit notes should include the following questions.

• Are a therapist’s skills needed to treat the illness or injury?
• Why does the patient require professional treatment, education or training?
• What skilled service did the therapist provide?
• How did the patient benefit from the specialized knowledge of the therapist?
• Did the skilled provider meet the accepted standards of medical practice?
• Was a 30-day reassessment conducted and documented as Medicare requires?
• Is the frequency and duration of services reasonable and necessary?

5. The services billed were not covered because the medical records submitted for review did not support homebound status. 

• A beneficiary is considered to be homebound if the following two criteria are met:  1) There exists a condition, due to illness or injury, that restricts the ability to leave the place of residence except with the aid of supportive devices, such as crutches, canes, wheelchairs and walkers; the use of special transportation; with the assistance of another person; or if leaving home is medically contraindicated. 2) There exists a normal inability to leave the home and leaving the home requires a considerable, taxing effort.

Tips to avoid this denial:  Documentation throughout the patient’s care process, not just upon admission, must have clinical evidence (specific to the patient) that proves the patient meets the homebound status criteria.  
Examples of acceptable homebound status documentation include:

• The patient is homebound due to recent hospitalization and experiences muscle weakness that requires the use of a walker and another person to leave home safely; the patient experiences shortness of breath, poor endurance, pain and decreased mobility, and an increased risk for falls.  
• The patient is homebound following a traumatic fall with injuries that require the use of a wheelchair and another person to leave home safely due to muscle pain or weakness, impaired balance and shortness of breath with exertion. The patient’s recent exacerbation of congestive heart failure or current cardiac status can contribute to taxing efforts that require frequent periods of rest.

Medical Review can be a very difficult experience, but ensuring that the above criteria have been met during the documentation of your patient charts can guarantee a more pleasant experience with medical review and decrease the chances of receiving a denial.  Compliance with the Medicare regulations and conditions of payment can be somewhat different than compliance with the CoPs, so agencies must understand that both are necessary for home health success in surveys, payment and medical review.