Audit and Probe Review Denials: How to avoid the basic administrative issues identified by Jurisdiction D.

Basic tips from Peggy

The following are the top five reasons for denial:

1. Requested documentation was not provided within the allotted time frame as referenced in the Medicare guidelines.


2. No office visit notes to determine medical necessity were submitted within 30 days of certification or within 90 days of recertification.

ANSWER: Obtain the accurate date the patient was seen. Often, it is just a matter of having that date and the correct physician.

3. No/invalid qualifying blood gas study submitted. For example, having the labs before you take the patient.

NOTE: Many of these are because the test was completed in a physician office, but was not documented.

4. No documentation to support diagnosis.

ANSWER: Once again, be sure to get the date the patient was last seen, as well as the name of the physician who wrote the order.

5. No documentation to support alternative treatment has been tried/considered. This is documentation that must be included within the physician’s notes, relating to medication treatment. It is possible that the information was already recorded, but the supplier did not obtain sufficient records to support on the first round.

Primary items to remember:

Who is actually “touching” this patient? What other physician, other than the family practitioner, is taking care of the patient?

Obtain this information immediately. Get the dates up front, and document them. You may include the date last seen and by whom on part C of the CMN. For example, you may notate the liter flow and delivery method on part C of the CMN, such that you have a complete “detailed” order as soon as physician signs the CMN.

As least 80 percent of the denials will overturn in the appeals process (because the supplier digs harder for what is needed!).


This means that the order intake staff and all members of the DME suppliers’ team HAVE to ensure everything is there “BEFORE” taking the patient and billing the claim (or at least prior to billing).

Prevention is the main thing we have to stress. Hiring lawyers to fight something that could have been prevented up front is very costly!