Quick Explanation
Denial code MH28 indicates that a payer has denied payment because there is no documented evidence that the provider monitored the patient's adherence to their prescribed medication regimen. This monitoring is typically a prerequisite for reimbursement in chronic care management, behavioral health, or high-risk pharmacotherapy services.
Common Causes for MH28
Denials with code MH28 typically happen for the following specific reasons:
- Failure to document a structured medication reconciliation, adherence check, or compliance discussion during the patient encounter.
- Omission of specific CPT Category II quality codes or HCPCS codes that designate medication adherence monitoring was performed.
- Lack of required laboratory or diagnostic verification (such as therapeutic drug level monitoring or urine drug screens) mandated by payer policy for high-risk medications.
- Inadequate clinical documentation in the electronic health record failing to specify that the patient's compliance, barriers, or side effects were reviewed.
How to Prevent MH28 Denials
To avoid receiving this denial in the future, implement these specific checks:
- Utilize standardized EHR templates that require providers to complete and document a medication adherence assessment during E/M and CCM visits.
- Incorporate relevant CPT Category II codes on claims to systematically report quality measures related to medication review and compliance.
- Set automated clinical alerts to prompt providers when scheduled therapeutic drug monitoring or laboratory screenings are due for patients on high-risk drugs.
- Conduct regular internal audits of clinical documentation to ensure compliance with payer-specific guidelines regarding chronic medication management.
Appeal Letter Template for MH28
If you believe this claim was denied incorrectly, you can use the following template to submit an appeal.
[Your Practice Header]
[Date]
[Payer Name]
[Appeals Department Address]
RE: Appeal for Claim [Claim Number]
Patient: [Patient Name]
ID: [Patient ID]
Date of Service: [Date]
Denial Code: MH28 - Medication adherence not monitored
Dear Appeals Department,
I am writing to appeal the denial of the above-referenced claim, which was denied with code MH28: "Medication adherence not monitored".
We are appealing the denial of this claim under code MH28, 'Medication adherence not monitored.' A review of the medical record for the date of service confirms that medication adherence was thoroughly assessed, discussed, and documented by the provider. The attached clinical notes explicitly detail the patient's current medication compliance, the absence of adverse side effects, and the provider's counseling on adherence strategies, fulfilling the criteria outlined in CMS and AMA guidelines for medication management and evaluation services. Because clinical documentation clearly supports that medication adherence was actively monitored, we request that this denial be reversed and the claim be paid in full.
Attached please find:
1. A copy of the original claim.
2. The relevant medical records supporting the service.
3. [Any other supporting documents].
We respectfully request that you reprocess this claim for payment.
Sincerely,
[Your Name]
[Title]
[Practice Name]
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