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January 2010 J1 Part A Medical Review Top Denial Reason Codes
1. Medical Review Downcode
Reason for Denial
The services billed were paid at a lower payment level. Documentation submitted for review should support the data on the MDS, paint a clear picture of the beneficiary’s medical condition, and meet coverage criteria. Based on medical review, the documentation submitted for review did not meet the criteria for the RUG code(s) billed. As a result, reimbursement has been adjusted to a lower payment level.
How to Avoid a Denial
To avoid medical review downcoding of billed RUG codes, submit all documentation to support the RUG code(s) billed. The MDS assessment that established the RUG code billed must be supported by the clinical documentation. If any portion of documentation to support the RUG code billed is not submitted, a downcode may result. When therapy RUG codes are billed, the following documentation must be submitted for review:
Reason for Denial
The MDS cannot be accessed in the National Repository.
How to Avoid a Denial
Ensure that the MDS has been entered into the National Repository prior to submitting request for payment to Medicare
Check all bills for accuracy and ensure that the MDS clinical assessment includes data for all covered days associated with the billing period.
3. Lack of Response to Medical Record Request
Submit the claim with Medical record
4. Information Provided Does Not Support the Medical Necessity for This Service
Reason for Denial
The claim was fully or partially denied, as we were unable to determine medical necessity with the documentation submitted for review.
How to Avoid a Denial
Submit all documentation to support medical necessity of the services billed. Include documentation for the “look back period(s).” This may include up to 30-45 days prior to the dates of service under review.
5. No Qualifying Hospital Stay Dates Were Shown in HIMR for This Skilled Nursing Facility
Reason for Denial
The service(s) billed [was/were] not covered by Medicare, as there is no qualifying hospital dates shown in Health Insurance Maintenance Record (HIMR) for this skilled nursing facility.
How to Avoid a Denial
The 3 consecutive calendar day stay requirement can be met by stays totaling 3 consecutive days in one or more hospitals. In determining whether the requirement has been met, the day of admission, but not the day of discharge, is counted as a hospital inpatient day. In addition, the qualifying hospital stay must be medically necessary.
1. Medical Review Downcode
Reason for Denial
The services billed were paid at a lower payment level. Documentation submitted for review should support the data on the MDS, paint a clear picture of the beneficiary’s medical condition, and meet coverage criteria. Based on medical review, the documentation submitted for review did not meet the criteria for the RUG code(s) billed. As a result, reimbursement has been adjusted to a lower payment level.
How to Avoid a Denial
To avoid medical review downcoding of billed RUG codes, submit all documentation to support the RUG code(s) billed. The MDS assessment that established the RUG code billed must be supported by the clinical documentation. If any portion of documentation to support the RUG code billed is not submitted, a downcode may result. When therapy RUG codes are billed, the following documentation must be submitted for review:
- Orders for therapy services signed and dated by the physician,
- A written therapy plan of treatment established by the physician after consultation with the therapist,
- The actual minutes of therapy rendered as documented on a log/grid or in the clinical documentation to support the minutes recorded on the MDS, and;
- Progress notes and any other documentation to establish the medical necessity of the services rendered.
Reason for Denial
The MDS cannot be accessed in the National Repository.
How to Avoid a Denial
Ensure that the MDS has been entered into the National Repository prior to submitting request for payment to Medicare
Check all bills for accuracy and ensure that the MDS clinical assessment includes data for all covered days associated with the billing period.
3. Lack of Response to Medical Record Request
Submit the claim with Medical record
4. Information Provided Does Not Support the Medical Necessity for This Service
Reason for Denial
The claim was fully or partially denied, as we were unable to determine medical necessity with the documentation submitted for review.
How to Avoid a Denial
Submit all documentation to support medical necessity of the services billed. Include documentation for the “look back period(s).” This may include up to 30-45 days prior to the dates of service under review.
5. No Qualifying Hospital Stay Dates Were Shown in HIMR for This Skilled Nursing Facility
Reason for Denial
The service(s) billed [was/were] not covered by Medicare, as there is no qualifying hospital dates shown in Health Insurance Maintenance Record (HIMR) for this skilled nursing facility.
How to Avoid a Denial
The 3 consecutive calendar day stay requirement can be met by stays totaling 3 consecutive days in one or more hospitals. In determining whether the requirement has been met, the day of admission, but not the day of discharge, is counted as a hospital inpatient day. In addition, the qualifying hospital stay must be medically necessary.
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