Denials
July – September 2023, Outpatient Services Medical Review Top Denial Reason Codes
We encourage all providers to review this information when filing claims to prevent denials and to ensure their claims are processed timely. The following information affects providers billing the 13X bill type in South Carolina, North Carolina, Virginia and West Virginia.
|
Rank |
Denial Code |
Denial Description |
# Claims |
|---|---|---|---|
|
1 |
No medical necessity |
4874 |
|
|
2 |
No Diagnosis/Documentation to support medical necessity (Bene Liable/ Provider Liable) |
3175 |
|
|
3 |
Service Is Subject to Prior Authorization and No UTN Is Present on the Claim |
166 |
|
|
4 |
Auto Denial - Requested Records not Submitted |
159 |
|
|
5 |
Documentation Submitted Does Not Support Medical Necessity |
98 |
|
|
6 |
NCD Denial - HCPCS/Diagnosis matched National Coverage Determination (NCD) table list ICD9-CM Deny Codes |
96 |
|
|
7 |
Item of Service Is Subject to Prior Authorization and No Prior Authorization Was Requested for the Item of Service |
64 |
July – September 2023, Inpatient Hospital and Psych Medical Review Top Denial Reason Codes
We encourage all providers to review this information when filing claims to prevent denials and to ensure their claims are processed timely. The following information affects providers billing the 11X bill type in South Carolina, North Carolina, Virginia and West Virginia.
|
Rank |
Denial Code |
Denial Description |
# Claims |
|---|---|---|---|
|
1 |
Auto Denial - Requested Records not Submitted |
32 |
|
|
2 |
LCD Denial - no medical necessity |
14 |
|
|
3 |
Need for Service/Item Not Medically and Reasonably Necessary |
2 |
|
|
4 |
DRG Code Changed to Reflect Actual Service Billed (Upcode) |
1 |
|
|
5 |
Documentation Submitted Does Not Support Medical Necessity for Inpatient Psychiatric Services |
1 |
|
|
6 |
Info Submitted Does Not Support Dates Billed |
1 |
|
|
7 |
No Orders for Inpatient Admission |
1 |
July – September 2023, Skilled Nursing Facility Medical Review Top Denial Reason Codes
We encourage all providers to review this information when filing claims to prevent denials and to ensure their claims are processed timely. The following information affects providers billing the 21X bill type in South Carolina, North Carolina, Virginia and West Virginia
|
Rank |
Denial Code |
Denial Description |
# Claims |
|---|---|---|---|
|
1 |
Medical Review Downcode |
36 |
|
|
2 |
Auto Denial - Requested Records not Submitted |
23 |
|
|
3 |
Certification Not Valid |
16 |
|
|
4 |
Not Medically and Reasonable Necessary |
14 |
|
|
5 |
Skilled nursing facility benefits are only available after an eligible covered hospital stay of at least 3 days |
10 |
|
|
6 |
Agree with Provider (Beneficiary Liable) |
8 |
|
|
7 |
SNF MDS is not in the National Repository |
4 |
|
|
8 |
Billed In Error |
3 |
|
|
9 |
LCD Denial - no medical necessity |
2 |
5D505 — Certification Not Valid
Reason for Denial
The certification or recertification is not submitted, not signed, not dated, or does not cover the dates of service in question.
To prevent this denial:
- A certification or recertification statement must be signed by an attending physician or a physician on the staff of the SNF who has knowledge of the case or a nurse practitioner who does not have a direct or indirect employment relationship with the facility, but who is working in collaboration with the physician, or a clinical nurse specialist who does not have a direct or indirect employment relationship with the facility, but who is working in collaboration with the physician. Initial certifications must be obtained at the time of admission, or as soon thereafter as is reasonable and practicable
- The routine physician’s admission order is not a certification of the necessity for post-hospital extended care services for purposes of the Medicare program
- When responding to a request for copies of medical records, submit the initial certification and/or subsequent recertifications related to the look back periods and the dates of service under review
For more information, refer to:
- CMS Manual System, Publication 100-08, Medicare Program Integrity Manual, Chapter 6 – Intermediary MR Guidelines for Specific Services, Section 6.3 (PDF)
- CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Chapter 8, Section 40 (PDF)
- Code of Federal Regulations (CFR)
- 42 CFR § 424.11(c) & 424.20 Requirements for post hospital SNF care