MAC Palmetto GBA has released its results for pre-payment denials under Targeted Probe and Educate (TPE) for July to September 2023.
Of 5,839 claims reviewed, 942 were denied. The top denial reasons included:
  1. Face-to-face encounter requirements not met: 110 denials.
  2. No Plan of Care or certification: 105 denials.
  3. No physician’s order for services or more than ordered: 47 denials.
  4. The documentation submitted wis insufficient to support that the skilled nurse services billed were reasonable and necessary: 40 denials.
  5. Homebound requirement not met: 32 denials.
Palmetto offers the following guidance to avoid face-to-face encounter denials:
 
Specific documentation related to face-to-face encounter requirements must be submitted for review. This includes, but is not limited to, the following:
  • A face-to-face encounter must occur no more than 90 days prior to the home health start of care date or within 30 days of the start of the home health care
  • Encounter was related to the primary reason the patient requires home health services
  • Encounter was performed by a physician or allowed nonphysician practitioner (NPP)
The certifying physician must also document the date of the face-to-face encounter. The face-to-face encounter can be performed by:
  • The certifying physician
  • The physician who cared for the patient in an acute or post-acute care facility (from which the patient was directly admitted to home health)
  • A nurse practitioner or a clinical nurse specialist who is working in collaboration with the certifying physician or the acute/post-acute care physician
  • A certified nurse midwife or physician assistant under the supervision of the certifying physician or the acute/post-acute care physician
The certifying physician’s and/or the acute/post-acute care facility’s medical record for the patient must contain the actual clinical note for the face-to-face encounter visit that demonstrates that the encounter:
  • Occurred within the required timeframe
  • Was related to the primary reason the patient requires home health services
  • Was performed by an allowed provider type
This information can be found most often in, but is not limited to the following examples:
  • Discharge summary
  • Progress note
  • Progress note and problem list
  • Discharge summary and comprehensive assessment