Medicare administrative contractor CGS has posted top denial reasons for Targeted Probe and Educate reviews from September 2022 through March 2023.
“Skilled nursing not medically necessary” accounted for more than 25% of all denied home health claims. The other top reasons were:
- Initial certification invalid;
- FTF missing/incomplete/untimely;
- Therapy visits not medically necessary; and
- Documentation does not support homebound.
For hospices, the top denial reasons was “terminal prognosis not supported,” accounting for nearly half of all hospice denials. The other top reasons were:
- Notice of Election invalid;
- NOE not present;
- Certification missing; and
- Face-to-Face Encounter invalid.