CGS monitors quarterly data for the top home health and hospice (HHH) medical review denial reasons. In addition to the quarterly data, you will find CGS and CMS resources to help prevent these denials. Below is a summary of the top medical review denials for the October – December 2019 quarter. Click the links below:
Home Health Top Medical Review Denial Reason Codes
5HC01: The physician certification was invalid since the required face-to-face encounter was missing/incomplete/untimely.
5HO02: The order(s) are incomplete as they must indicate discipline, frequency duration, and treatment.
5HC09: The initial certification was missing/incomplete/invalid, therefore the recertification episode is denied.
5HY01: 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.
5HN18: Skilled nursing services were not medically necessary.
Hospice Top Medical Review Denial Reason Codes
5PM01: According to Medicare hospice requirements, the information provided does not support a terminal prognosis of six months or less.
5PX06: The notice of election is invalid because it doesn’t meet statutory/regulatory requirements.
5PC01: The physician narrative statement was not present or was not valid.
5PC09: The hospice plan of care does not meet the requirements set forth in the code of federal regulations
5PC07: Certification does not include the 6-month terminal prognosis statement