Wednesday, November 27, 2013

CGS Home Health Edit for Hypertension Continues to Show a High Denial Rate

The home health widespread edit 5023T continues to show a high denial rate upon quarterly data analysis, and therefore will remain an edit.  This edit, “5023T”, is a widespread topic edit that selects claims for pre-pay review based on the hypertension diagnoses and length of stay greater than two episodes of care.  Claims that were reviewed for this edit last quarter received a denial rate of 85%.  This is down from the 95% denial rate a year ago but remains high. The top denial for these claims was 5HMED, not medically necessary.

Supportive Documentation of Medical Necessity
Although the topic of the edit is driven by a diagnosis, the denials were not due to “coding”.  The entire medical record is reviewed, and the top denial is related to documentation of medical necessity of the skilled services, primarily for skilled nurse visits for observation and assessment. For a skilled service of observation and assessment to be covered by Medicare, there must be clear documentation of the patient’s condition that warrants this service.  Typically, documentation of changes in diagnosis, exacerbations, medication or treatment changes that continue to put the beneficiary at risk for further plan of care changes shows the medical necessity for observation and assessment.  The Medicare Benefit Policy Manual (CMS Pub 100- 02), Ch. 7, §, states “Observation and assessment of the patient’s condition by a nurse are reasonable and necessary skilled services where there is a reasonable potential for change in a patient’s condition that requires skilled nursing personnel to identify and evaluate the patient’s need for possible modification of treatment or initiation of additional medical procedures until the patient’s treatment regimen is essentially stabilized.”  Nursing may continue observation and assessment when there have been continued changes and risks for further need to change the plan of care.

The Medicare Benefit Policy Manual (CMS Pub 100-02), Ch. 7, §, also states, “However, observation and assessment by a nurse is not reasonable and necessary to the treatment of the illness or injury where these indications are part of a longstanding pattern of the patient’s condition which itself does not require skilled services and there is no attempt to change the treatment to resolve them.”

In summary, your documentation must clearly support the medical necessity of all services provided.  For further examples and discussion of all types of skilled services, please reference the Medicare Benefit Policy Manual (CMS Pub 100-02), Ch. 7, at

Obtained from: