Jurisdiction 6 HHH Targeted Probe and Educate: Medical Review Topics

Topic	CPT Code(s)	Common Denials	Resources
Home Health Services - Medical Necessity ICD-10 M17, M54	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 - Medical Necessity ICD-10 Z47-Z47.89	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 - HIPPS	N/A	55H3V– The documentation did not support the medical necessity for the skilled nursing services. 55HTP– The initial certification was missing/incomplete/invalid; therefore the recertification episode was denied. 55HTW– The physician certification was invalid since the required face-to-face encounter was missing/incomplete/untimely.	CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 7, Sections 30.5, 40.1
Home Health Services - Increased Reimbursement	N/A	55H3V– The documentation did not support the medical necessity for the skilled nursing services. 55HTA – The certification was missing or invalid. 55HTP– The initial certification was missing/incomplete/invalid; therefore the recertification episode was denied.	CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 7, Sections 30.3, 30.5, 40.1
Home Health Services - Length of Stay	N/A	55H2B– The documentation submitted does not support homebound status. 55H3V– The documentation did not support the medical necessity for the skilled nursing services. 55HTP– The initial certification was missing/incomplete/invalid; therefore the recertification episode was denied.	CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 7, Sections 30.1, 30.5, 40.1
Hospice Care- Q-Codes	Q5003, Q5004	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 - Length of Stay > 180 days	N/A	55H1L – 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 Code of Federal Regulations, Title 42, Part 418.24
Hospice - Increased Reimbursement	N/A	55H1L – 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 Code of Federal Regulations, Title 42, Part 418.24
Hospice - New Provider	N/A	55H1L – 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 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 the 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.	Local Coverage Determination Hospice- Determining Terminal Status CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 9, Sections 20.1, 20.2.1, 40.1.5 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 8/22/2023