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January 29, 2018

Home Health Probe & Educate Round 2

The Centers for Medicare & Medicaid Services (CMS) issued the Medicare Learning Network (MLN) Matters® article SE1635External PDF, "Continuation of the Home Health Probe and Educate Medical Review Strategy."

The following provided key points for Round 2, as well as results from Round 2 reviews.

Round 2 Key Points

  • A sample of 5 claims for pre-payment review from each home health agency (HHA) was selected, excluding those providers who had 5 claims reviewed in Round 1, with zero or one claim in error out of the 5 claims. NOTE: This means that 5% of HHAs who submit claims to CGS were exempt from Round 2.
  • Claims reviewed for valid face-to-face (FTF) encounter documentation, medical necessity, and compliance with the CMS coverage guidelines in the CMS-1611-F, Calendar Year (CY) 2015 Home Health Prospective Payment System (HH PPS) Final RuleExternal Website.
  • At the conclusion of the probe review of a provider's 5 claims, a letter was sent to the HHA with claim-by-claim rationales. The letter also offered providers the opportunity to request one on one education with a clinician knowledgeable of each claim decision.

Round 2 Results
Under the Round 2 Probe & Educate medical review strategy, CGS paid 2,277 claims in full and 4,631 claims were either partially or fully denied. The top three reasons for denials are outlined below.

FTF Documentation Denials accounted for approximately 1,180 (25%) of the total Probe and Educate denials.

  • Actual FTF encounter document not submitted
  • Certifying physician did not document the date of the FTF encounter
  • Community physician was not identified when a physician who would not be following the patient after discharge signed the certification
  • Estimated length of skilled services was not documented in the recertification document
  • Required elements for initial certification (initial plan of care, initial certification, initial encounter documentation) were not submitted for recertification

Refer to the CGS Home Health Coverage Guidelines Web page for a variety of resources on the home health FTF encounter.

No Response to Additional Development Requests (ADRs) accounted for approximately 816 (18%) of the total Probe and Educate denials. A medical review ADR is generated for claims meeting the Probe & Educate criteria.

  • Documentation must be received by CGS within 45 calendar days
  • Claims will be denied if the documentation is not received by day 46

For information to ensure the necessary steps to submit requested documentation timely, refer to the CGS Medical Review Additional Development Request (ADR) Process Web page.

Documentation did not support medical necessity of therapy services accounted for approximately 457 (10%) of the total Probe and Educate denials. Refer to the CGS Physical Therapy Web page for documentation tips, access to the Medicare Benefit Policy Manual (CMS Pub. 100-02, Ch. 7) therapy information and the Local Coverage Determination for physical therapy services.


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