End-stage renal disease (ESRD)
Top denial/partial denial reasons and high-level results are listed below from each round of JH ESRD TPE reviews that have been conducted thus far by us. If you have questions about your individual results, please contact the nurse reviewer assigned to your review for additional information. Additional rounds of review will be utilized when the targeted topic demonstrates a continued need for review with newly identified providers.
The most common reasons for denial or partial denials are the following:
1. Medical necessity - The documentation submitted does not support medical necessity as listed in coverage requirements.
2. Insufficient documentation – Insufficient documentation was provided to support the services as billed to Medicare. Our Medical Review makes multiple attempts to correct these error types before completion of the review. Below are the following denial reasons for insufficient documentation that we were not able to resolve:
The physician's order for hemodialysis was missing.
The physician's order for dialysis was not signed by the physician.
Treatment flow sheets for dates of service billed were missing.
The medical record lacks documentation to support extra treatment.
The medical record lacks documentation of medication administration.
The medical record lacks the lab result to support services billed.
The documentation submitted supports this service is an integral part of another service received on the same day and cannot be billed separately.