Jurisdiction K HHH Targeted Probe and Educate: Medical Review Topics

Topic	CPT Code(s)	Common Denials	Resources
Home Health Medical Necessity	N/A	55H3V– The documentation did not support the medical necessity for the skilled nursing services. 55HTA – The certification was missing or invalid. 55HTH – The physician's plan of care and/or certification was present and signed but the signature was not dated.	CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 7, Sections 30.2.6, 30.3, 30.5, 40.1 CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4
Home Health Services - Therapy Services	N/A	55H2B– The documentation submitted does not support homebound status. 55H4D– The medical documentation submitted did not show that the therapy services were reasonable and necessary and at a level of complexity which requires the skills of a therapist.	CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 7, Sections 30.2.6, 30.3, 30.5, 40.1
Home Health Bound	N/A	55HTP– The initial certification was missing/incomplete/invalid; therefore the recertification episode was denied. 55H2B– The documentation submitted does not support homebound status.	CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 7, Sections 30.1.1, 30.1.2
Home Health Services with Length of Stay > 90 days	N/A	55H3V – The documentation did not support the medical necessity for the skilled nursing services. The skilled nurse is not reasonable and necessary to provide general assessment, medication administration and reminders, to evaluate compliance to the plan of care or for home health aide supervision. 55H2B – The documentation submitted does not support homebound status	CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 7, Sections 30.1, 40.1
Home Health Services with Admitting Diagnosis Z47	N/A	55H2B – The documentation submitted does not support homebound status. 55HTB - The physician's plan of care is missing or invalid	CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 7, Sections 30.1, 30.2, 40.1, 40.2
Hospice Services with length of Stay > 365 days	N/A	55H1R– The notice of election is invalid because it does not meet statutory/regulatory requirements.	Local Coverage Determination Hospice- Determining Terminal Status CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 9, Sections 10, 20.1, 20.2.1, 20.2.1.2. Code of Federal Regulations, Title 42, Part 418.24
Hospice - General Inpatient > 7 days	N/A	55H1M– The documentation indicates the general inpatient level of care was not reasonable and necessary. Therefore, payment was adjusted to routine home care rate. 55H1R– The notice of election is invalid because it does not meet statutory/regulatory requirements. 55H1S – The face-to-face encounter requirements were not met. 55H1Y – The physician narrative statement was not present or was not valid.	Local Coverage Determination Hospice- Determining Terminal Status CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 9, Sections 10, 20.1, 20.2.1, 20.2.1.2. Code of Federal Regulations, Title 42, Part 418.24
Hospice - General Inpatient Q-code(s)	N/A	55H1L – According the Medicare Hospice requirements, the information provided does not support a terminal prognosis of six months or less. 55H1R– The notice of election is invalid because it does not meet statutory/regulatory requirements. 55H1S – The face-to-face encounter requirements were not met.	Local Coverage Determination Hospice- Determining Terminal Status CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 9, Sections 10, 20.1, 20.2.1, 20.2.1.2. Code of Federal Regulations, Title 42, Part 418.24
Hospice - Alzheimer's Diagnosis	N/A	55H1L – According the Medicare Hospice requirements, the information provided does not support a terminal prognosis of six months or less. 55H1R– The notice of election is invalid because it does not meet statutory/regulatory requirements. 55H1U – The initial certification was not signed by the physician. 55H1Y – The physician narrative statement was not present or was not valid.	Local Coverage Determination Hospice- Determining Terminal Status CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 9, Sections 10, 20.1, 20.2.1 Code of Federal Regulations, Title 42, Part 418.24

*Not an all-inclusive list of resources

If a non-response to an ADR occurs, the claim may deny with the reason code 56900. A 56900 denial will negatively impact a provider's error rate and may result in additional rounds of TPE review. By implementing TPE best practices and responding to ADRs, this is an easily preventable denial.

Additional References

Revised 5/6/2024