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January 22. 2020

Top Home Health and Hospice Medical Review Denial Resources

CGS monitors quarterly data for the top home health and hospice (HHH) medical review denial reasons. This information is made available to HHH providers on our website. Simply access the "Medical Review" link in the left side navigation menu, then select Tools, Tracking, & Resources. Scroll down to the Medical Review Denials heading to find links to the HHH denial reason codes, and the top 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.

Denial Code Denial Description #of Claims Denied % of Claims Denied
5HC01 The physician certification was invalid since the required face-to-face encounter was missing/incomplete/untimely. 182 22%
5HO02 The order(s) are incomplete as they must indicate discipline, frequency duration, and treatment. 104 12%
5HC09 The initial certification was missing/incomplete/invalid, therefore the recertification episode is denied. 102 12%
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. 93 11%
5HN18 Skilled nursing services were not medically necessary. 54 6%
Denial Code Denial Description #of Claims Denied % of Claims Denied
5PM01 According to Medicare hospice requirements, the information provided does not support a terminal prognosis of six months or less. 44 47%
5PX06 The notice of election is invalid because it doesn't meet statutory/regulatory requirements. 14 15%
5PC01 The physician narrative statement was not present or was not valid. 7 7%
5PC09 The hospice plan of care does not meet the requirements set forth in the code of federal regulations 7 7%
5PC07 Certification does not include the 6-month terminal prognosis statement 6 6%

Please share this information with your appropriate staff.

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