Jurisdiction 6 HH+H Targeted Probe and Educate: Medical Review Topics

Topic	CPT Code(s)	Common Denials	Resources
Home Health Services - Medical Necessity ICD-10 Z47-Z47.89	N/A	55H3V– The documentation did not support the medical necessity for the skilled nursing services. 55HTA – The certification was missing or invalid. 55HTH – The physician's plan of care and/or certification was present and signed but the signature was not dated.	CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 7, Sections 30.2.6, 30.3, 30.5, 40.1 CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4
Home Health Services - HIPPS	N/A	55H3V– The documentation did not support the medical necessity for the skilled nursing services. 55HTP– The initial certification was missing/incomplete/invalid; therefore the recertification episode was denied. 55HTW– The physician certification was invalid since the required face-to-face encounter was missing/incomplete/untimely.	CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 7, Sections 30.5, 40.1
Home Health Services - Increased Reimbursement	N/A	55H3V– The documentation did not support the medical necessity for the skilled nursing services. 55HTA – The certification was missing or invalid. 55HTP– The initial certification was missing/incomplete/invalid; therefore the recertification episode was denied.	CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 7, Sections 30.3, 30.5, 40.1
Home Health Services - Length of Stay	N/A	55H2B– The documentation submitted does not support homebound status. 55H3V– The documentation did not support the medical necessity for the skilled nursing services. 55HTP– The initial certification was missing/incomplete/invalid; therefore the recertification episode was denied.	CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 7, Sections 30.1, 30.5, 40.1
Hospice Care- Q-Codes	Q5002, Q5003, Q5004	The election statement and/or the election statement addendum did not meet CMS requirements. The specific issue is identified on the individual claim(s). 55H1L – According to the Medicare Hospice requirements, the information provided does not support a terminal prognosis of six months or less. 55H1S – The face-to-face encounter requirements were not met.	Local Coverage Determination Hospice- Determining Terminal Status CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 9, Sections 10, 20.1, 20.2.1, 20.2.1.2. Code of Federal Regulations, Title 42, Part 418.24
Hospice - Length of Stay > 180 days	N/A	The election statement and/or the election statement addendum did not meet CMS requirements. The specific issue is identified on the individual claim(s). 55H1L – The information provided does not support a terminal prognosis of six months or less. 55H1S – The face-to-face encounter requirements were not met.	Local Coverage Determination Hospice- Determining Terminal Status CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 9, Sections 10, 20.1, 20.2.1 Code of Federal Regulations, Title 42, Part 418.24
Hospice - Increased Reimbursement	N/A	The election statement and/or the election statement addendum did not meet CMS requirements. The specific issue is identified on the individual claim(s). 55H1L – The information provided does not support a terminal prognosis of six months or less. 55H1S – The face-to-face encounter requirements were not met.	Local Coverage Determination Hospice- Determining Terminal Status CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 9, Sections 10, 20.1, 20.2.1 Code of Federal Regulations, Title 42, Part 418.24
Hospice - New Provider	N/A	The election statement and/or the election statement addendum did not meet CMS requirements. The specific issue is identified on the individual claim(s). 55H1L – The information provided does not support a terminal prognosis of six months or less. 55H1S – The face-to-face encounter requirements were not met.	Local Coverage Determination Hospice- Determining Terminal Status CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 9, Sections 10, 20.1, 20.2.1 Code of Federal Regulations, Title 42, Part 418.24
Hospice - General Inpatient > 7 days	N/A	The election statement and/or the election statement addendum did not meet CMS requirements. The specific issue is identified on the individual claim(s). 55H1M – The documentation indicates the general inpatient level of care was not reasonable and necessary. Therefore, payment was adjusted to the routine home care rate. 55H1S – The face-to-face encounter requirements were not met.	Local Coverage Determination Hospice- Determining Terminal Status CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 9, Sections 20.1, 20.2.1, 40.1.5 Code of Federal Regulations, Title 42, Part 418.24

**Not an all-inclusive list of resources

If a non-response to an ADR occurs, the claim may deny with the reason code 56900. A 56900 denial will negatively impact a provider's error rate and may result in additional rounds of TPE review. By implementing TPE best practices and responding to ADRs, this is an easily preventable denial.

Additional References

Revised 7/22/2024