Palmetto GBA has released its top reasons for pre-payment review denials for the first three months of 2025.
The top of the list is the usual suspects: face-to-face encounters, plan of care/certification, documentation of services rendered and medical necessity for therapy.
At No. 5: The documentation submitted was insufficient to support that the skilled nurse services billed were reasonable and necessary.
“The key to Medicare coverage is for the documentation to ‘paint a picture’ of the beneficiary’s overall medical condition indicating the need for skilled service,” Palmetto notes in describing the reason for this type of denial.
“Skilled observation and assessment beyond a three-week period may be justified when documentation supports the likelihood of further complications or an acute episode,” Palmetto states. “However, observation and assessment are not reasonable and necessary when the documentation indicated that the abnormal findings are part of a longstanding pattern of the patient’s condition and there is no attempt to change the treatment to resolve them.”