“Skilled nursing not medically necessary” caused 25% of recent denials under Targeted Probe and Educate review from CGS, a Medicare Administrative Contractor in 15 states and Washington, D.C.
This was the top denial reason for claim reviews between April and June 2025, ahead of “initial certification invalid” (21.4%) and “face-to-face documentation missing, incomplete or untimely” (14.2%).
One of the top challenges with the justification for skilled nursing is that the documentation from each and every visit is expected to “reflect the need for the skilled medical care provided.” (Medicare Benefit Policy Manual, Chapter 7, §40.1.1)
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“To support medical necessity, it must be clear that home health can actually do something to effect change and restore or maintain patient condition and function,” says Joe Osentoski, senior consultant for Gateway Home Health Coding & Consulting of Sterling Heights, Mich.
Examples of diagnoses that may face pushback when justifying home health needs include essential hypertension, osteoarthritis, hypothyroidism, dysphagia, Alzheimer’s disease, hypertensive coronary vascular disease, hypercholesterolemia and skin alterations, he notes.
While these diagnoses satisfy coding requirements, agencies may struggle to show how the patient’s situation is relevant and acute, Osentoski explains.
Clinicians who come to home health from other settings or health care backgrounds may not be accustomed to the level of documentation that in-home care involves, says Apryl Swafford, QA Manager with SimiTree Healthcare Consulting in Hamden, Conn. While staffing shortages may have some agencies desperate to get boots on the ground, team leaders must first ensure clinicians understand what’s required of them, she stresses.
“Make sure you’re going over it at onboarding, then when you do your skills check-off every year,” Swafford says. Staff in charge of reviewing charts should also know how to identify situations in which a clinician may need increased education around documentation, she notes.