Corporate

Hospice Top Medical Review Denial Reason Codes

October - December 2018

The following information provides hospice medical review denial data related to the most recent calendar quarter. Please review this information and the educational resources to assist with preventing these types of denials. Refer to the Hospice Denial Reason Codes Web page for a complete list of denial codes.

Rank Denial Code Denial Description # of Claims Denied % of Claims Denied
1 5PM01 According to Medicare hospice requirements, the information provided does not support a terminal prognosis of six months or less. 42 53%

Resources:

Rank Denial Code Denial Description # of Claims Denied % of Claims Denied
2 5PX06 The notice of election is invalid because it doesn’t meet statutory/regulatory requirements. 13 16%

Resources:

Rank Denial Code Denial Description # of Claims Denied % of Claims Denied
3 5PC01 The physician narrative statement was not present or was not valid. 7 9%

Resources:

Rank Denial Code Denial Description # of Claims Denied % of Claims Denied
4 5PC08 Face-to-Face Encounter requirements not met. 4 5%

Resources:

Rank Denial Code Denial Description # of Claims Denied % of Claims Denied
5 5MP02 According to Medicare hospice requirements, the documentation indicates the general inpatient level of care was not reasonable and necessary.  Therefore, payment will be adjusted to the routing home care rate. 4 4%

Resources:

Updated: 01.25.19

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