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ADR Denial Reasons

ADR Denial Reasons

5CF2F - F2F Requirement Not Met

The services billed were not covered because the documentation submitted for review did not include documentation of a face-to-face encounter.

How to prevent this denial

The face-to-face encounter must occur no more than 30 calendar days prior to the start of the third benefit period and no more than 30 calendar days prior to every subsequent benefit period thereafter.

Specific documentation related to the face-to-face encounter requirements must be submitted for review. This includes, but is not limited to, the following:

The hospice physician or nurse practitioner who performs the encounter must attest in writing that he or she had a face-to-face encounter with the patient, including the date of the encounter
The attestation, its accompanying signature, and the date signed must be a separate and distinct section of, or an addendum to, the recertification form, and must be clearly titled
When a nurse practitioner performs the encounter, the attestation must state that the clinical findings of that visit were provided to the certifying physician for use in determining whether the patient continues to have a life expectancy of six months or less, should the illness run its normal course

5CFIP ADR Denial 5CFIP - Invalid Plan of Care Submitted

The claim has been fully or partially denied as the documentation submitted for review did not include a valid plan of care for all or some of the dates billed.

For a beneficiary to receive hospice care covered by Medicare, a plan of care (POC) must be established before services are provided. The POC is developed from the initial assessment and comprehensive assessment and services provided must be consistent with the POC.

How to prevent a denial:

The POC must contain certain information to be considered valid. This includes:
- Scope and frequency of services to meet the beneficiary's/family's needs
- Beneficiary-specific information, such as assessment of the beneficiary's needs, management of discomfort and symptom relief
- Services that are reasonable and necessary for the palliation and management of the beneficiary's terminal illness and related conditions
The plan of care must be reviewed, revised and documented as frequently as the beneficiary's condition requires, but no less frequently than every fifteen 15 calendar days.

For further information refer to:

Change Request 6982
Code of Federal Regulations, 42 CFR – Section 418.56 and 418.200
CMS Internet-Only Manuals (IOMs), Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4
This article is available on the Palmetto GBA Web Site (www.PalmettoGBA.com/HHH) using the Palmetto GBA Web site Search feature: Responding to a Hospice Additional Documentation Request (ADR)

5FNOA ADR Denial 5FNOA - Unable to Determine Medical Necessity of HIPPS Code Billed as Appropriate OASIS Not Submitted

The services billed were not covered because the home health agency did not submit the OASIS to the State repository for the HIPPS code billed on the claim. The provider should ensure that the OASIS that generated the HIPPS code for the claim is submitted to the state repository and submitted with the medical records in response to an ADR.

To prevent this denial:

Under the HHPPS, an OASIS is a regulatory requirement. If the home health agency does not submit the OASIS, the medical reviewer cannot determine the medical necessity of the level of care billed and no Medicare payment can be made for those services.

For further information on the above Medicare coverage issue, references include, but are not limited to, these resources:

For more information refer to: