Medical Review


Medical review is the collection of information and clinical review of medical records by Palmetto GBA to ensure that payment is made only for services that meet all Medicare coverage, coding and medical necessity requirements. Medical review activities are directed toward areas where data analyses indicate questionable billing patterns.

The goal of the medical review program is to reduce payment errors by identifying and addressing billing errors made by providers concerning coverage and coding. To achieve the goal of the medical review program, Palmetto GBA:

  • Proactively identifies patterns of potential billing errors concerning Medicare coverage and coding made by providers through data analysis and evaluation of other information (e.g., complaints)
  • Reviews data analysis reports
  • Takes action to prevent and/or address the identified error
  • Publishes local medical review policies via Local Coverage Determinations (LCDs) to provide guidance to the public and medical community about when items and services will be eligible for payment under the Medicare statute

Additional Resources





Medical Review Articles

56900 - Auto Deny - Requested Records Not Submitted5FT10 and 5AT10 - Documentation Does Not Support Homebound Status5F041 and 5A041 - Information Provided Does Not Support Medical Necessity for this Service5FF2F and 5TF2F - Face-to-Face Encounter Requirements Not MetTargeted Probe and Educate Progress Update: Hospice - NCLOS5CFH6 - Initial Certification Not TimelyTargeted Probe and Educate Progress Update: Hospice - Beneficiary Sharing5FFH9 - Physician Narrative Statement Not Present or Not ValidTargeted Probe and Educate Progress Update: Hospice - GIP - General Inpatient CareHospice Routine Home Care Targeted Probe and Educate (TPE) Refinement5CFTF - Face-to-Face Encounter Requirements Not Met5CFNP - No Plan of Care SubmittedTargeted Probe and Educate Progress Update: Hospice - NCLOS5CF91 - Hospice GIP Reduction - Services Not Reasonable/NecessaryTargeted Probe and Educate Progress Update: Home Health Progress Update5CFH9 - Physician Narrative Statement Not Present or Not Valid5CFIP - Invalid Plan of Care SubmittedTargeted Probe and Educate Progress UpdateTargeted Probe and Educate Progress Update for JM Home Health Bene Sharing5FNOA - Unable to Determine Medical Necessity of HIPPS Code Billed as Appropriate OASIS Not Submitted5F023 - No Plan of Care or Certification5CF01 - General Inpatient Services Not Reasonable and Necessary5CFH4 - Initial Certification Not Signed5FF2F - Face-to-Face Encounter Requirements Not Met5CHG3 - MR HIPPS Code Change Due to Partial Denial of TherapyTargeted Probe and Educate VideoTargeted Probe & Educate (TPE) Provider ContactMedical Review Intent to Reopen Process for Non-Receipt of Medical Record DenialsPalmetto GBA Partnering with Providers to Get it Right the First TimeWe Have Noticed a Significant Increase in 56900 Auto Denials - Requested Records Not SubmittedActive Service Specific Postpayment Medical ReviewsResponding to a Hospice Additional Documentation RequestHospice Certification ErrorsHome Health Denials for Incorrect Billing of 'Attending/Other' Names and NPIsHome Health: Therapy ADRsHospice Documentation TipsHHH Denial Reason Code CrosswalkResponding to a Home Health Additional Documentation Request (ADR)Charge Denial Rate (CDR) CalculatorMedical Review Program and Targeted Probe and Educate HandoutADR Response CalculatorTargeted Probe and Educate Progress UpdateHome Health Postpayment Results for October to December 2020 Postpayment Service-Specific Probe Results for Hospice (General Inpatient Care) for October through December 2020CMS MLN Fact Sheet: Medical Record Maintenance and Access RequirementsHome Health Medical Review Top Denial Reason Codes: January through March 2021Claim Selection Process for Targeted Probe and Educate: S B6000 vs. S B6001Targeted Probe and Educate Resumed September 1, 2021Postpayment Service-Specific Probe Results for Hospice General Inpatient Care for January through March 2021Postpayment Service-Specific Probe Results for Hospice: General Inpatient Care for April through June 2021Postpayment Service-Specific Probe Results for Home Health for January through March 2021Postpayment Service-Specific Probe Results for Home Health for April through June 2021Access TPE Letters Electronically: Job AidJuly - September 2021, Home Health Medical Review Top Denial Reason CodesTargeted Probe and Educate Process ModuleMedicare Record Authentication: Tips for PhysiciansMedicare Medical Records: Signature Requirements, Acceptable and Unacceptable Practices5CNER: The Election Statement Is Invalid5CNOE: No Valid Election Statement SubmittedJM Parts A, B and Home Health and Hospice Targeted Probe and Educate Active Medical Review List5T072, 5F072: No Physician Order for Services or More than Ordered5A301, 5F301: Information Provided Does Not Support the Medical Necessity for Therapy Services5CF36, 5FF36: Not Hospice Appropriate5T070, 5F070: Visits, Supplies, DME Billed Not Documented or Not Documented As UsedMedicare Documentation Signature TimelinessMedical Review Program

Last Updated: 04/21/2022