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:
- Face-to-face encounter requirements not met: 110 denials.
- No Plan of Care or certification: 105 denials.
- No physician’s order for services or more than ordered: 47 denials.
- The documentation submitted wis insufficient to support that the skilled nurse services billed were reasonable and necessary: 40 denials.
- 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