Home health agencies greatly benefit from being aware of the top reasons for claims denials by MACs. It helps save valuable time and resources in rectifying denied claims and reduces the likelihood of receiving Additional Development Requests (ADRs) from CMS, ensuring timely reimbursement and a healthy cash flow. Furthermore, proactively avoiding common claim issues maintains survey readiness, improves billing and coding accuracy, and, most importantly, enhances patient care.
CGS:
- Skilled nursing services not deemed medically necessary
- Missing, incomplete, or invalid initial certification leading to denied recertification episode
- Missing, incomplete, or untimely face-to-face encounters leading to denied physician certification
- Insufficient medical documentation to show the necessity of therapy services
- Missing signatures on a physician or allowed practitioner’s plan of care and/or certification
Palmetto:
- Not meeting face-to-face encounter requirements
- Failure to submit requested records
- No plan of care or certification
- Lack of supporting information for the medical necessity of a service
- No physician’s orders for services
NGS:
- No response from requests for medical records
- Missing, incomplete, or invalid certification
- Skilled nursing services not deemed medically necessary
- Not meeting daily care requirements
Avoiding Setbacks with Accurate Coding
Your coding process is vital to ensure that key information is available, accurate, and consistent across all documentation to support claims.
Given the Patient-Driven Groupings Model (PDGM) guidelines on the relevance of face-to-face encounter documentation and primary diagnosis coding, it is crucial to have a valid and accurate diagnosis code in the claim. This not only helps prevent claim denials but also maximizes the potential for reimbursement.