Denial Reason Codes for Home Health per Cahaba GBA
Services may be denied when individual case documentation reveals that specific coverage requirements are not met. These coverage requirements are based directly on sections of the Social Security Act (Sections 1870 and 1879), which discuss home health services. When payment is denied, a Medicare Summary Notice (MSN) is issued to the beneficiary detailing the Medicare claims processed by the contractor.
Home health agencies receive a remittance advice (RA), which communicates claim determinations. The RA displays the ANSI reason code in the "RC" or "REM" column. The reason code denial definition can be viewed online in the Fiscal Intermediary Standard System (FISS) or may be found in the CMS Understanding the Remittance Advice guide.
Medical denials are made upon medical review when:
- Care is determined to not be reasonable and medically necessary
- Homebound criteria are not met
- Skilled nursing care is not intermittent
- Visits are not documented
- HIPPS code billed is not validated by documentation in the medical record
Administrative denials are denials made for all other reasons. Examples of administrative denials include:
- Excess of orders (more visits made than ordered by the physician)
- Services billed prior to physician signing Plan of Care
- Services exceed definition of part-time
- Administrative visits for nursing assessment
- Supervisory visits
- ESRD related visits
- No physician certification
- Dependent service with no skilled service ordered
- Statutory exclusions no skilled service ordered
- Statutory exclusions
Excluded services (drugs and biologicals, routine foot care, personal comfort items, orthopedic shoes and appliances)
- Services provided by another government agency, including services to prisoners
Courtesy of Care2Learn's Clinical Care for Therapy Newsletter