Be sure your documentation will back up claims with this red-flag diagnosis.
If your Parkinson's claim becomes caught up in Cahaba GBA's edit for the diagnosis, it will get denied four out of five times.
In an edit Cahaba used for home health agency claims with a diagnosis of Parkinson's disease, a length of stay greater than 60 days and therapy utilization of 10 or more visits, medical reviewers denied a whopping 80 percent of claims, the regional home health intermediary reports in its March newsletter to providers. The RHHI says it plans to continue the edit this quarter.
#1 reason: "The highest percentage of denials was related to medical necessity," Cahaba explains in the article about edit 5THBY. Typically the documentation didn't support a continued need for nursing or therapy visits.
Nursing visits for observation and assessment commonly go unsupported in the record. "Observation and assessment by a nurse is not reasonable and necessary where [clinical] indications are part of a longstanding pattern of the patient's condition, and there is no attempt to change the treatment to resolve them," Cahaba stresses.
Therapy visits need specific support such as objective measurements of progress. "Subjective statements such as 'walking further' or 'progressing well' do not alone support the coverage of further therapy visits," the RHHI cautions.
#2 reason: Providers often use Parkinson's as the primary diagnosis in error. "Parkinson's disease is a chronic disorder, and although it greatly affects a patient's health, it may not be the most specific skilled reason home health is currently seeing the patient," Cahaba advises. "The primary diagnosis is the chief reason for home health care and represents the most acute condition with the most intensive skilled services to be provided."
The article, including more tips to avoid denials, is at
https://www.cahabagba.com/part_a/education_and_outreach/newsletter/200803_rhhi.pdf on p. 36. • If you've run into claims rejections following the March 1 National Provider Identifier deadline, don't just resubmit claims and cross your fingers.
"Providers whose claims are rejected and returned to them should immediately contact their contractor before resubmitting that claim or submitting new claims for services provided to Medicare beneficiaries," the Centers for Medicare & Medicaid Services in-structs in a message to providers.
As of March 1, CMS required Medicare providers to include an NPI on claims. You can still include a Medicare legacy number too, but by May 23 all Medicare claims must be NPI-only in the main fields.
One the eve of the March 1 deadline, CMS reported an 88.5 percent rate of claims with NPIs submitted to durable medical equipment Medicare administrative contractors (DME MACs). Part A providers were submitting 99.9 percent of claims with NPIs. • State governors at the recent National Governors Association meeting in Washington, DC discussed increasing home care utilization to [...]
