adr process for the snf: medicare part b claims

ADR Process for SNF Medicare Part B Claims

HARMONY UNIVERSITYThe Provider Unit of

Harmony Healthcare International, Inc. (HHI)

Presented by:

Carrie Mullin, OTR/L, RAC-CT

Claims Review Specialist

Harmony Healthcare International, Inc.

About Carrie

Claims Review Specialist for Harmony Healthcare International, Inc.

MS OTR/L, RAC-CT

Experience:

Extensive history with long term care as an Occupational Therapist, Director of Rehabilitation, and as Regional/Corporate Consultant for Harmony Healthcare.

Specialized in working with facilities on preparing medical records for ADRs and appeals, as well as assisted facilities in preparation for ALJ hearings.

Partnered with law firms to assist facilities with both internal and OIG investigations.

Copyright © 2014 All Rights Reserved 2

Objectives

I. Learner will understand Medicare Part B guidelines

II. Learner will be able to summarize goals of Medicare Medical Reviews

III. Learner will be able to identify and articulate examples of the Medicare Medical Review Process

IV. Learner will be able to identify strategies for interdisciplinary management of Medicare documentation requests and appeals

3Harmony Healthcare International, Inc.Copyright © 2014 All Rights Reserved

Prevention

The key to preventing denials is documentation of skilled services provided

The key to documenting skilled services provided is understanding the Medicare requirements for coverage

Harmony Healthcare International, Inc. 4Copyright © 2014 All Rights Reserved

Common Auditors

Significant increase in frequency of Medical Review

Office of Inspector General (OIG) Reports

Department of Justice (DOJ) Review

Zone Program Integrity Contractor (ZPIC)

Recovery Audit Contractor (RAC)

Budget cuts

Expect to be reviewed

Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 5

Medicare Part B Regulations for Therapy Services


Medicare Part B: Skilled Therapy

Entitled to Part B Beneficiaries, pay additional to have Part B

Services must be skilled, reasonable and necessary

Part B reimburses 80% of fee screen. Additional insurance may cover the additional 20% (Medicaid, Medex).


Skilled Therapy Under Medicare Part B

The Medicare cap on outpatient rehabilitation therapy services was instituted under the Balanced Budget Act of 1997 as a combined cap on speech-language pathology (SLP) and physical therapy (PT) services to Medicare beneficiaries

Separate cap on occupational therapy (OT)



Current therapy cap for Physical and Speech Therapy combined is $1,920 for calendar

year 2014

Current therapy cap for Occupational Therapy combined is $1,920 for calendar

year 2014

Services that meet the exceptions criteria and report the KX modifier on billing log will be paid beyond this limit with clinical justification


Medicare Part B – Dispelling the Myths


Treating all the patient’s regardless of the medical conditions. The deciding factors are always whether the services are considered reasonable, effective treatments for the patient’s condition and require the skills of a therapist.

In the case of a progressive degenerative disease, for example, service may be intermittently necessary to determine the need for assistive equipment and establish a program to maximize function


Skilled Therapy Under Medicare Part B – MYTHS!

There must be 3 days of supporting documentation reflecting an ongoing condition prior to therapy interventions?

Therapy cannot treat them they have exceeded the therapy cap or they just discharged from therapy?

Therapy just discharged them, therapist can provide treatment off a screen only?

Therapist treat Medicare Part B patient when the Medicare Part A and HMO patients census is low?


Medicare Part B

Documentation Review


Rules & Regulations Part B Service Delivery

Local Medical Review Policy (LMRP) are published by each Intermediary

Review to understand intermediary’s specific requirements and expectations related to Medicare B therapy billing

Therapy documentation should reflect the wording and terminology used in the LMRP in order to support our claim


Skilled Rehabilitation MD Orders

The service must be ordered by a physician

Frequency and duration are required

Must be current for entire time services are required

“Evaluation and treatment as indicated” must be clarified


Physician Certification

The therapy intervention must relate directly and specifically to an active written treatment regimen established by the physician after any needed consultation with the qualified rehabilitation therapy professional and must be reasonable and necessary to the treatment of the beneficiary’s illness or injury necessary to the treatment of the beneficiary’s illness or injury


Physician Certification

Minimally required every 90 days

Harmony recommends every 30 days

Continued physician oversight

Ensure plan continues appropriate

Summarize progress every 30 days

700 or 701 no longer required

No longer a required format


Skilled Rehabilitation/MD Involvement

MD involvement to prevent injuriesMedicare allows the professional therapist to develop a suggested plan of treatment and to begin providing services based on the plan prior to MD signatureMD signature required before facility bills Medicare

Timely considered less than 30 days Recommend at time therapy initiates

MD Faxed signatures acceptable


Method of Service Delivery

Individual therapy – one on one intervention

Group therapy (97150)

Concurrent therapy should be billed as group treatment under Med B

Co-treatment time needs to be split between the therapists



Evaluation


Onset Date

Date of the primary or treatment diagnosis for which therapy services are being rendered Must be of a recent onset. Chronic conditions greater than 3 months are at risk for denial.

Emergency matters: choking, falling, etc. Require immediate attention and there is no need to “wait” for documentation.

For chronic diagnoses, indicate the date of the change or deterioration in the patients condition that now necessitates therapy services (acute exacerbation date)

Onset Date

Nursing notes should support a change in condition requiring a skilled therapy services

Nursing needs to clearly outline the precipitating event(s) to Rehab referral

There is no federal requirement for 3 days of nursing documentation to initiate Part B services


Diagnosis

Medical diagnosis supports deficits identified on evaluation being treated

Reporting on the UB-04. What is the process between therapy and billing?

Ensure chronic codes that are not related are not used

Dementia

UTI


Diagnosis

Indicate the Medical DX that has resulted in the therapy disorder

Relate to the current plan of care for therapy

Represent the most intensive services (over 50% of the revenue code billed)

Relevant to the problem to be treated E.g. O.A. with treatment diagnosis of “pain in the joint” or “difficulty walking”


Reason for Referral

Avoid statement such as “to purchase private wheelchair” or “New admission”

Provide the reason for the referral as it relates to the primary or treating diagnosis or condition and the mechanism of injury

For chronic conditions, an objective description of the changes in function (acute exacerbation) that now necessitate skilled therapy should be indicated


Reason for Referral Examples

“falls x 3 in the last 2 weeks”

“no longer ambulating to the dining room”

“..decline in their transfer ability, this is supported through staff interview”

“developed stage 2 pressure ulcer on coccyx”

“exacerbation of M.S. and is now having difficulty with ……

“unable to sit upright in current chair and requires frequent repositioning from staff”

“5 %weight loss and is currently p.o.. intake is 50%”


Prior Level of Function

It has been determined that the prior level of function is one area reviewers are using to generate denials

Prior level of function must be highly detailed and paint a picture of what the patient was doing at home

Address problems identified on evaluation

Discipline specific


Prior Level of Function

A thorough prior level of function is the basis for the patient’s long term goals

Interview the patient as well as family or staff caregivers

If info is not obtained at the time of evaluation, document in an addendum as soon as it is obtained


Evaluation

Potential is good or excellent

For stated goals

Goals should be appropriate so they can be achieved

Not related to medical status

Reason for Referral


Evaluation

Previous Therapy

Reflects recent therapy related to this problem only

State previous therapy and reason (gait, ADL)

Documentation must support reason why seen again after a recent discharge (6 months)


Evaluation

Narrative should summarize patient need, potential and reason a skilled therapist is needed

Focus on functional status verses medical

Avoid negative statements


Writing Goals

Treatment goals are of two types, separate or in combination

The functional outcome goal identifies the desired client performance resulting from therapy (dress, ambulate, articulate)The enabling goal identifies the method by which a therapist enables a client to accomplish the goal (increase ROM, improve memory, increase activity tolerance)


Writing Goals

Treatment goals should:

Be realistic

Have a positive effect on the quality of the patient’s life

Be measurable and quantifiable

Be related to function

Appropriately reflect the patient’s needs


Writing Goals

Treatment goals consist of:

Short-term goals are interim targets; steps to achieve the long-term goals. Achieved in 2 weeks.

Long-term goals are what the client will have achieved at the time of discharge


Writing Goals

Treatment Goal Components

Functional Outcome – (required) the desired result

Qualifier – (required) objective measure

Techniques or Strategies – verbal cues, energy conservation techniques

Condition – requirements necessary for correct performance; description of the environment, adaptive equipment


Cognitive Goal Setting

Attention: “Patient will attend to ADL tasks for a 30 minute session with rare cues to regain attention”

Sequencing: “Patient will properly sequence bathing and dressing tasks 3 out of 5 trials with supervision only, using visual aide provided by OT”

Memory: “Patient will demonstrate recall of AM self care schedule when prompted by OT 60 minutes following completion of session”

Copyright © 2014 All Rights Reserved 36Harmony Healthcare International, Inc.

Impaired Cognition

Transmittal AB-01-136, 09/25/2001 states that contractors may not install edits that result in the automatic denial of services based solely on the ICD-9-CM codes for Dementia


Impaired Cognition

Establishing Medical Necessity:

Primary Diagnosis

Secondary Diagnosis

Objective findings to support services in MR

Specific details as to why these services are medically necessary based on the therapist’s objective that will be supported by the functional goal attainment as outlined in the treatment plan and progress notes


Impaired Cognition

2001 CMS Program Memorandum “Medical Review of Services for Patients with Dementia”

Because dementia is a diagnostic term with broad clinical implications, it may not support the medical necessity of a Medicare covered benefit when used alone

Utilize the primary diagnosis that most accurately reflects the need for the provided service


Impaired Cognition

Which most accurately reflects the need for the provided service?

“A provider using physical therapy to treat a patient with an unsteady gait due to Alzheimer’s dementia may enter either ICD-9 code 331.0 (Alzheimer’s Disease) or ICD-9 code 781.2 (Abnormality of Gait) as the primary diagnosis”

Similarly, Speech therapy to treat a patient with Aphasia related to Alzheimer’s dementia may enter either ICD-9 code 331.0 (Alzheimer’s Disease) or ICD-9 code 784.3 (Aphasia) as the primary diagnosis

Diagnosis code must be supported by the Medical Record


Duplication of Services

Rehab goals can appear to be demonstrating a duplication of services. High risk of denial

Commonly seen goal areas:

Independence with bed mobility

Transfers

Ambulation


Re-Evaluation

Re-evaluations are appropriate when a significant change occurs or there is a need for formal re-evaluation to establish initial baseline data not previously recorded. The billing codes for re-evaluation should be used in these instances only as a one-time charge. The re-evaluation codes should not be billed for completion of the monthly summaries, discharge summaries or when sending general information into the physician.



Treatment Notes

Treatment Notes

Treatment encounter notes are required for every treatment day, and every therapy service

The treatment encounter note must record:The name of the treatment, intervention or activity

The time spent in services represented by timed codes

The total treatment time

The identity of the individual providing the intervention



Medicare Benefit Policy Manual

The purpose of these notes is simply to create a record of all treatments and skilled interventions that are provided and to record the time of the services in order to justify the use of billing codes on the claim

Documentation is required for every treatment day, and every therapy service



Treatment Notes need to include:

Date of treatment

Identification of each specific intervention/modality provided

Total timed code treatment minutes and total treatment time in minutes. Total treatment time includes the minutes for timed code treatment and untimed code treatment.

Signature and professional identification



To further support services, consider also documenting:

Patient self-report

Adverse reaction to intervention

Communication/consultation with other providers (e.g., supervising clinician, attending physician, nurse, another therapist, etc.)



Significant, unusual or unexpected changes in clinical status

Equipment provided

Any additional relevant information the qualified professional finds appropriate

Documentation Requirements Treatment Notes

Documentation is required for every treatment day, and every therapy service

Treatment notes are not required to document medical necessity or appropriateness of the ongoing therapy services


Documentation RequirementsTreatment Notes

The purpose of the Treatment Note is simply to create a record of all treatments and skilled interventions that are provided

Record of the time of each service is required to justify the use of billing codes on the claim



The signature and identification of the supervisor is not required to be on each Treatment note, unless the supervisor actively participated in the treatment

The supervisors identification must be clear in the Plan of Care or Progress Report



It is not required to document in the Treatment note the amount of time for each specific intervention/modality

Pub. 100-02, chap. 15, section 230.3B

This may be recorded voluntarily, but this will be indicated in the billing



Skilled InterventionsSkilled:

Trained in use of one-handed dressing techniques to facilitate upper body dressing

Educated in use of core body exercises to increase trunk strength and stability during ADLs

Instructed in scanning techniques to help locate food on their plate

Non-Skilled:Encouraged patient to perform ADLs at sink

Helped patient ambulate from smooth to inclined surfaces

Observed patient attempting to get out of bed without the side rail

Why Co-Treatment?

Increase the benefit of the therapeutic session

More comprehensive assessment of patients’ needs

More complex tasks can be safely trialed

Improved minute management


RAI User’s Manual

Medicare Part AWhen two clinicians (therapists or therapy assistants), each from a different discipline, treat one resident at the same time with different treatments, both disciplines may code the treatment session in full


RAI User’s Manual

Medicare Part B: “Therapists, or therapy assistants, working together as a "team" to treat one or more patients cannot each bill separately for the same or different service provided at the same time to the same patient”


RAI User’s Manual

The decision to co-treat should be made on a case by case basis and the need for co-treatment should be well documented for each patient

Per the RAI User’s Manual: “Because co-treatment is appropriate for specific clinical circumstances and would not be suitable for all residents, its use should be limited”



Progress Notes

Progress Notes

Progress Reports: Progress reports should be completed every 10 treatment days or 30 calendar days whichever is less. These will include components required in the weekly progress summary while also requiring:

Updated goals and treatment plan with identification of significant improvement in functional skills

Weekly recommended

10th visit must be by PT or OTR and documented


Progress Notes

Clinician’s are required to participate in treatment during the Progress Report Period

Documentation/proof of the clinician’s participation in treatment is required in the Treatment note or in the Progress report via the clinician’s signature


Progress Notes

Progress reports written by assistants supplement the reports of the clinicians (between 10 visits)

These notes need to consist of:

Date of the beginning of the interval the report refers to

Date that the report was written (within the interval)

Objective reports of the patient’s subjective statements

Objective measurements or description of changes in status relative to each goal being addressed

Signature of the professional and the date it was written


Progress Notes

Progress Report Content

Assessment of the patient’s response to the services

Progress towards each of the treatment goals

Documentation of any treatment variations with the associated rationale

Progress within levels of care

Re-assessment and establish new goals


Progress Notes

Document the need for continued services by a skilled therapist verses the use of restorative nursing

Non-skilled services include: Observing or monitoring, general practice techniques, and reviewing previously learned material

Skilled services include: Educating the patient, assessing mobility skills, evaluating the effectiveness of, instructing the patient in a progressive exercise program, or modifying the treatment program


Progress Notes

Identify the expectation for further progressIdentify the resident’s risk factors that may be eliminated by receiving the therapy services

Justify the frequency, duration and intensity of the treatment

Any change in the treatment plan would required physician clarification orders



Non-Supportive Skilled Documentation

Plateau in progress

Still requires

Patient is unable to follow directions

Patient has poor rehab potential

Patient refuses to participate in therapy (without documentation of root of refusal)

Within normal limits


First progress note to support skilled therapy services is 4 weeks after therapy began. Quoted statements from patient refusing therapy and asking to end the therapy sessions/program, yet services continued without documented improvement.



“Slow, steady gains” described in progress notes but comparison of function is without change from one week to the next

When a plateau is suspected, therapy goals should be adjusted and progress documented more frequently to justify treatment



Discharge Notes

Discharge

Upon completion of each program a discharge summary should be entered on the same form for which weekly and or daily notations on the patient’s progress were made

It is important to give thorough a synopsis beginning with a comparison between the initial level of function and discharge status


Discharge

List all techniques and methods trialed even failed attempts

Discharge setting with cues for re-referral for skilled therapy


Documentation RequirementsDischarge Note

A discharge note is required for each episode of treatment

The discharge note is a Progress Report written by the clinician

The discharge note covers the reporting period form the last Progress report to the date of discharge



Unanticipated discharge:

Data related to discharge not noted in the previous Progress Report will require the clinician writing the final note to rely on treatment notes and verbal reports of the assistant or qualified personnel



Discharge anticipated within 3 treatment days of Progress Report:

Clinician may provide objective goals, when met will authorize the assistant or qualified personnel to discharge the patientThe clinician must verify services provided prior to discharge required the skills of a therapistServices were provided or supervised by a clinician



The clinician should consider the discharge note the last opportunity to justify the medical necessity of the entire treatment episode for review purposes

The discharge note includes all the treatment provided since the last Progress Report



The discharge note needs to indicate that the therapist reviewed the notes and agrees to the discharge

The clinician may include additional information:

Summarize the entire episode of treatment

Justify services that may be extended beyond those usually expected for the patient’s condition


Denial Reasons: Audit Focus


Reasons for Denials

Services related to activities for the general good and welfare of patients (e.g., general exercises to promote overall fitness and flexibility, and activities to provide diversion or general motivation), do not constitute physical therapy services for Medicare purposes

Diathermy and Ultrasound heat treatments for the treatment of asthma, bronchitis, or any other pulmonary condition are considered not reasonable and necessary, and therefore, non-covered


Reasons for Denials

Electrical Stimulation used to treat motor function disorders, such as multiple sclerosis, is considered investigational and therefore, non-coveredElectrical Stimulation used in the treatment of facial nerve paralysis, commonly known as Bell’s Palsy, is considered investigational and therefore, non-coveredHome health physical therapy is not covered to treat Skilled Nursing Facility patients


Reasons for Denials

Work hardening/conditioning is a non-covered service. These services relate solely to specific work skills and do not provide any diagnostic or therapeutic benefit for the patient that requires physical rehabilitation.

Failure to document a complete treatment plan as outlined in Documentation Required section

Services determined not to require the skills of a therapist


Reasons for Denials

Lack of documentation relating to the patient having the potential to show significant progress

Goals are not functional (i.e., patient will perform 10 repetitions of upper extremity exercises with the yellow theraband)

The amount, frequency and duration of services were not reasonable, given the patient’s current status


Reasons for Denials

Gains were not significant and there was no indication of carryover of the functional task

The outcome of therapy treatment was not documented

Duplication of services between physical therapy and occupational therapy

Skilled therapy was provided when non-skilled maintenance services would have been more appropriate

The therapist ignored the patient’s prior level of function and set unrealistic goals


Technical Denial Reasons

Response to Additional Documentation Request (ADR) did contain documentation requested

Documentation not received within requested time frame

Physician Certification not signed or missing

Therapy Billing logs do not support billingPart B - 8 Minute Rule

Illegible documentation

Hospital documentation was not submitted


Clinical Denial Reasons

Documentation did not support medical necessity

Documentation does not support daily skilled intervention by a qualified therapist

Documentation in the medical records must support continued progress


Denial Reasons

Services provided were likely clinically appropriate but the documentation provided to reviewers did not support:

Technical requirements

Medical necessity

The skills of a therapist were required

Functional outcome


Denial ReasonsLack of Supportive Documentation

The medical record does not support the patient had a change in function

Nursing Documentation

Physician Documentation


Denial ReasonsDeconditioning

Skills of a therapist are not required to maintain function or improve strength and endurance

Services related to activities for the general good and welfare of patients (e.g., general exercises to promote overall fitness and flexibility, and activities to provide diversion or general motivation), do not constitute physical therapy services for Medicare purposes

Practicing of previously taught exercises does not require the skills of a therapist


Denial ReasonsPrior Level of Function

Prior level of function was illegible. Prior level of function was blank.

Patient's functional level had not changed when compared to his prior level of functioning documented in the medical record.


Denial ReasonsRehab Potential

The medical record did not support that the condition of the patient would improve materially in a reasonable and generally predictable period of time

Poor Rehab potential


Denial Reasons Goals

Goals are not functional (i.e., patient will perform 10 repetitions of upper extremity exercises with the yellow theraband)

Duplication of services between disciplines


Denial Reasons Lack of Functional Progress

Gains were not significant and there was no indication of carryover of the functional task

Lack of documentation relating to the patient having the potential to show significant progress

No significant improvement with functional ability

The outcome of therapy treatment was not documented



Skilled Interventions

Medicare will support continued services when the patient is not making progress if there is documentation that multiple skilled interventions have been trialed

It is appropriate to give each trial an adequate amount of time to determine if the patient will progress

Denial Reasons Cognitive Therapy

The record documented a diagnosis of Alzheimer’s disease. SLP documentation does not support further significant practical improvement could be expected.

Medical justification for ST services is not established

Speech treatment cognition for dementia

Poor progress with cognition


Medicare Medical Review Process


Harmony Healthcare International


Chapter 8 Revisions

December 2013


Why Update the Policy Manual?

CMS SettlementCMS revised the Medicare Benefit Policy Manual (December 2013) and will revise other Medicare Manuals to correct suggestions that Medicare coverage is dependent on a beneficiary "improving"

New policy provisions state that skilled nursing and therapy services necessary to maintain a person's condition can be covered by Medicare


Medicare Benefit Policy Manual Update

“Coverage for such skilled therapy services does not turn on the presence or absence of a beneficiary’s potential for improvement from therapy services, but rather on the beneficiary’s need for skilled care. Therapy services are considered skilled when they are so inherently complex that they can be safely and effectively performed only by, or under the supervision of, a qualified therapist. (See 42CFR §409.32) These skilled services may be necessary to improve the patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration of the patient’s condition.” - December 2013



(continued)

Therapy services are considered skilled when they are so inherently complex that they can be safely and effectively performed only by, or under the supervision of, a qualified therapist. (See 42CFR §409.32) These skilled services may be necessary to improve the patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration of the patient’s condition” - December 2013



“The services must be provided with the expectation, based on the assessment made by the physician of the patient’s restoration potential, that

The condition of the patient will improve materially in a reasonable and generally predictable period of time; or,

The services must be necessary for the establishment of a safe and effective maintenance program; or,

The services must require the skills of a qualified therapist for the performance of a safe and effective maintenance program” – December 2013


RAI User’s Manual Update

RAI User’s Manual September 2013:Therapy services can include the actual performance of a maintenance program in those instances where the skills of a qualified therapist are needed to accomplish this safely and effectively

However, when the performance of a maintenance program does not require the skills of a therapist because it could be accomplished safely and effectively by the patient or with the assistance of non-therapists (including unskilled caregivers), such services are not considered therapy services in this context


Appeals Process:

Know Your Reviewer



Medicare Administrative Contractors

101


2003 mandated that the Secretary of Health & Human Services replace Part A FIs and Part B carriers with Medicare Administrative Contractors (MACs)

CMS established MACs as multi-state, regional contractors responsible for administering both Medicare Part A and Medicare Part B claims



CMS relies on a network of MACs to process Medicare claims, and MACs serve as the primary operational contact between the Medicare Fee-For-Service program, and approximately 1.5 million health care providers enrolled in the program



Collectively, the MACs and the other Medicare claims administration contractors process nearly 4.9 million Medicare claims each business day, and disburse more than $365 billion annually in program payments



Centers for Medicare & Medicaid Services (CMS) contracts with Medicare Administrative Contractors (MACs) to assist with local claims processing and the first level appeals adjudication function



Under probe reviews, contractors may examine 20-40 claims per provider for provider-specific problems

Contractors also conduct widespread probe reviews (involving approx. 100 claims) when a larger problem, such as a spike in billing for a specific procedure, is identified



Section 521 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) included provision aimed at improving the Medicare fee-for-service appeals process

Part of the provisions mandate that all second-level appeals (for both Part A and Part B), also known as reconsiderations, be conducted by Qualified Independent Contractors (QICs)



Recovery Audit Contractors

108



The Recovery Auditors Program Mission The Recovery Auditor detect and correct past improper payments so that CMS can implement actions that will prevent future improper payments:

Providers can avoid submitting claims that do not comply with Medicare rules

CMS can lower its error rate

Taxpayers and future Medicare beneficiaries are protected

109



If you bill fee-for-service programs, your claims will be subject to review by the Recovery Auditors

Target areas are posted on the RACs’ websites

110



The Recovery Audit Review Process: Recovery Auditors review claims on a post-payment basis

Recovery Auditors use the same Medicare policies as Carriers, FIs and MACs: NCDs, LCDs and the CMS Manuals

Three types of review:Automated (no medical record needed)

Semi-Automated (claims review using data and potential human review of a medical record or other documentation)

Complex (medical record required)

Recovery Audits look back three years from the date the claim was paid

Recovery Auditors are required to employ a staff consisting of nurses, therapists, certified coders and a physician CMD

111



The appeal process for Recovery Audit denials is the same as the appeal process for Carrier/FI/MAC denials

“Discussion Period” by phone in the first 15 days of denial

If you disagree with the Recovery Auditor’s determination:

File within 30 days to avoid recoupment

Up to 120 days to appeal

Interest will still accrue during the appeal process

112

IDT Goals

Each auditing agency has a slightly different agenda. Understand what their goals are.

Most auditing agencies hire nurses, therapists, and coding experts to review medical records

If your reviewer is a nurse or a coding expert, they may not see the skilled services the same way the therapy staff does


IDT Goals

A detailed PREP outlining the skilled services is imperative

Include definitions of standardized tests used, explanations of diet textures, details of specific procedures and techniques

Why is a decline should be considered a “significant decline”?

Assume someone from another discipline may be reviewing the record and detail the PREP accordingly


Appeal and ALJ Hearing Strategies



ADR ResponseAnd

Appeal Packages


Additional Development Requests

Medicare Contractors send providers additional development request (ADR) letters requesting additional documentation

The ADR letters will be mailed and /or the claim in question will be in status location S B6001 that identifies claims in FISS that are in an ADR status/location


The Appeal

It is important to read the ADR or denial letter thoroughly as the letters will assist the facility in gathering the appropriate information

Review the list of items provided in the decision statement to include in the medical record

Consider additional info not listed that will support the services provided


Monitor the Appeal

Internal tracking system to monitorWhen ADR or denial was received

When package was sent out

Final results of the review



Do not submit replacement/duplicate claims for the ones pending in medical review

The submission of replacement/duplicate claims will result in claim denial, rejection or recoupment and will

This will p r o l o n g the medical review process



When the claim is finalized, the claim will have paid in full or part, or denied

If you disagree with the decision, you can request a redetermination/1st level of appeal within 120 days of the determination (date on the remittance advice)



If the documentation needed to make a medical determination is not received, the claim may be denied as records not received timely and these claim denials are issued with Remittance Advice Code N102/56900



CMS guidelines allow contractors the time frame of 60 days to complete the review from the date on which the last of the requested medical records is received



The Appeal


Harmony Healthcare International, Inc. 125

The Appeal

Copyright © 2014 All Rights Reserved

Assign a team leader to oversee the preparation of the denial packageWork as a team to gather pertinent information for the Medicare Appeal Review the medical record to ensure completeness

The Appeal

The following team members are beneficial in this process:

MDS Coordinator

Director of Nursing Unit Managers (consider)

Restorative Nursing program Manager

Director of Therapy Any therapy professionals involved in the patient’s care

Social Services

Dietary

Additional team members who participated in care


The Appeal Package

Use a Checklist!

Make sure all team members review the medical record with the checklist to ensure all items are included, all items are dated, and all items are signed


The Appeal Package

Items to includeInclude all information in the medical record for period requested AND from the look back period of the billed MDS RUG

MD re-certifications for skilled stay for billed dates:

If certification is signed by a NP, be aware that there may be a request for the facility to submit an attestation letter verifying no direct or indirect employment relationship with the SNF


The Appeal Package

Items to include Pre admission data if applicable

Nurses notes the support a decline in function and referral to therapy

Case Manager notes

Care Plans that related to the functional decline

Dietary or Wound documentation


The Appeal Package

Items to include MD orders

MD notes

Signature log for all staff members documenting in the medical record during the dates in question, including printed name, credentials and handwritten signatures


The Appeal Package

Items to include Documentation of all therapies provided

Evidence of MD supervision

Evaluations even if it did not occur in period

Treatment notes and Progress notes

Therapy billing logs

Any other documentation that relates to the condition for which services were rendered.


The Appeal Package

Important to know the consequences if the facility does not submit all necessary paperwork

Facility needs to review the packet carefully to avoid a technical denial based on missing information including signatures


The Appeal Package

Each team member should review the package as a whole

The team leader should have a final look prior to submitting the appeal

PREP Letter Proper Reimbursement Explanation Paper

Always keep a copy of the packet sent to the reviewing agency


Appeals Process

PREP

Include a statement of position letter with the medical record documentation to the reviewing agency explaining the services provided to the patient


Monitor the Appeal

Internal tracking system to monitorWhen ADR or denial was received

When package was sent out

Final results of the review


Monitor the Appeal



Redetermination

and

Reconsideration


Redetermination and Reconsideration

If a claim is initially denied, there is action the facility can take

The first stage is the Redetermination

The next step is a Reconsideration


Redetermination

An examination of a claim by a review agency who is different from the agency who made the initial determination

The facility has 120 days from the date of receipt of the initial claim determination to file an appeal

A minimum monetary threshold is not required to request a determination


Redetermination

Request for redetermination may be filled on Form CMS-20027 available at http://www.cms.hhs.gov/CMSForms/CMSForms/list.asp#TopOfPage


http://www.cms.hhs.gov/CMSForms/CMSForms/list.asp

http://www.cms.hhs.gov/CMSForms/CMSForms/list.asp

Redetermination

Requests not made on Form CMS-20027 must include:

Beneficiary name

Medicare Health Insurance Claim (HIC) number

Specific service and/or items(s) for which a redetermination is being requested

Specific date(s) of service


Redetermination

Requests not made on Form CMS-20027 must include:

Name and signature of the party or the representative of the party (Usually the administrator of the building)

The name and address of the facility


Redetermination

Include an appeal letter that outlines the argument for coverage

Brief explanation of the hospitalization (if one occurred)

Past medical history

Status of patient on admission

List of the skilled nursing services provided to the patient


Redetermination

Appeal Letter

An explanation of skilled therapy services provided to the patient

Medicare guidelines used in the skilled care decision making process, if applicable


Redetermination

Any additional supporting documentation not submitted during the Help letter phase from the medical record should be submitted along with the redetermination request

Highlight

Add sticky tabs

The redetermination request should be sent to the contractor that issued the initial determination


Redetermination

Contractors will generally issue a decision within 60 days of receipt of redetermination request in the form of:

A letter

A Medicare Redetermination Notice (MRN)

Revised remittance advice


Reconsideration

If the request for redetermination results in a denial, a reconsideration can be requested

A QIC will conduct the reconsideration request

The QIC reconsideration process allows for an independent review of medical necessity by a panel of physicians or other health-care professions

A minimum monetary threshold is not required to request a reconsideration


Reconsideration

A written reconsideration request must be filed within 180 days of receipt of the redetermination

Instructions are provided on the Medicare Redetermination Notice (MRN)

A Request for reconsideration may be made on Form CMS-20033. This form will be mailed with the MRN.


Reconsideration

If Form 20033 is not used, request must contain:

Beneficiary name

Medicare Health Insurance Claim (HIC) number

Specific service(s) and/or item(s) for which the reconsideration is requested

Specific date(s) of service


Reconsideration

Documents to include

Name and signature of the party or the representative of the party (usually the administrator of the building)

Name of the contractor that made the determination

Name and address of the facility


Reconsideration

Include a letter outlining the argument for payment

Brief explanation of the hospitalization (if one occurred)

Past medical history

Status of patient on admission

List of skilled nursing services provided to patient

Explanation of skilled therapy services provided

Medicare guidelines used in skilled care decision- making process, if applicable


Reconsideration

The request should clearly explain why the facility disagrees with the redetermination

A copy of the MRN, and any other supportive documentation, should be sent with the reconsideration request to the QIC identified in the MRN


Reconsideration

If facility submits documentation after the reconsideration request has been filed, the QIC can extend the time they have to make their decision

Additionally, any evidence noted in the redetermination as missing and any other evidence relevant to the appeal, must be submitted prior to the issuance of the reconsideration decision


Reconsideration

Evidence not submitted at the reconsideration level may be excluded from consideration as subsequent levels of appeal unless you show good cause for submitting the evidence late


Reconsideration

Reconsiderations are conducted on-the-record; and in most cases, the QIC will send its decision to all parties within 60 days of receipt of the request for reconsideration

The decision will contain detailed info on further appeal rights if the decision is not fully favorable


Reconsideration

If the QIC cannot complete its decision in the applicable timeframe, it will inform the appellant of their right to escalate the case to an ALJ


A Successful ALJ Hearing


ALJ Overview

After the redetermination and reconsideration process, if at least $130 remains in controversy following the QIC’s decision, the facility may request an ALJ hearing within 60 days of receipt of the reconsideration

The facility must send a notice of the ALJ hearing request to the QIC on the hearing request form or in the written request


ALJ Overview

A letter to request the ALJ hearing should simply highlight the most pertinent reasons justifying payment


ALJ Overview

ALJ hearings are generally held by video-teleconference (VTC) or by telephone

If the facility prefers not to have a VTC or telephone hearing, they may ask for an in-person hearing, but they must demonstrate the necessity for an in-person hearing


ALJ Overview

The ALJ will determine whether an in-person hearing is warranted on a case-by-case basis

Facilities may also ask the ALJ to make a decision without a hearing (on-the-record). CMS or its contractors may participate in an ALJ hearing, but they must provide notice to the ALJ and all parties of the hearing.


ALJ Overview

ALJ will generally issue a decision within 90 days of receipt of the hearing request

The timeframe may be extended for a variety of reasons including, but not limited to:

The case being escalated from the reconsideration level

The submission of additional evidence not included with the hearing request

The request for an in-person hearing

The facility’s failure to send notice of the hearing request to other parties and

The initiation of discovery if CMS is a party


ALJ Overview

If the ALJ does not issue a decision within the applicable timeframe, you may ask the ALJ to escalate the case to the Appeals Council level


Appeal Rights

Medicare Appeals Council ReviewIf the facility is dissatisfied with the ALJ’s decision, may request review by Medicare Appeals Council

No requirements regarding the amount of money in controversy

The request must be submitted in writing within 60 days of receipt of ALJ’s decision and must specify the issues and findings that are being contested


Appeal Rights

Medicare Appeals Council ReviewGenerally, the Appeals Council will issue a decision within 90 days of receipt of a request. Timeframe may be extended for various reasons, such as the case being escalated from an ALJ hearing

If a decision is not issued within timeframe, facility may ask the Appeals Council to escalate the case to the Judicial Review level


Appeal Rights

Medicare Appeals Council ReviewIf at least $1,260 or more is still in controversy following the decision, the facility may request judicial review before a U.S. District Court Judge

Appellant must file request for review within 60 days of receipt of the Appeals Council’s decision


ALJ

Hearing Preparation


ALJ Hearing Preparation

Appeal Process

Discuss and study CMS Guidelines

Discuss type of ALJ hearing (video, phone, in person) to anticipate the format

Goals of the Hearing

Inform the Judge of skilled services

Get the claim paid


ALJ Hearing Preparation

Team Preparation

Medical record review

Outline of speaking points

Select a point person for the hearing

Team input


ALJ Hearing

Hearing ProcessPrepare the facility designated hearing room for video or phone hearings

Judge’s assistant will initiate the phone contact (test phone lines and speakers)

Introductions

Statement by facility

Offer to fax any pertinent documents discussed during the hearing


ALJ Hearing

Organize documentation

Keep pertinent notes or forms at your finger tips

Number the pages for reference

Have the staff that worked with patient on the call

Speak respectfully, clearly, slowly

Provide a concise summary


ALJ Hearing

Be prepared to answer questions prepared by the Judge

Why did the patient require skilled therapy when they were hospitalized for a UTI?

Where does the medical record state that continued therapy services were necessary after the initial date in question?

Explain why skilled care continued although the notes indicate the patient did not have an exacerbation of medical condition?


ALJ Hearing

Be prepared to answer questions asked by the Judge

When did the patient get discharged from therapy services?

Why do the daily nursing notes state the patient was ambulating ad lib, yet physical therapy continued to provide skilled treatment?


Conclusion

Don’t wait for an ADR to analyze your processes

Work as a team

Keep track and be timely

Understand skilled care criteria

Give good clinical care


Successful Reviews

Include all requested documentation

What is your medical record telling the reviewer?

Technical Requirements

Clinical Requirements

Include additional documentation

Support skilled coverage requirements have been met for rehabilitation and nursing services provided

Support the MDS RUG Score billed


The Importance of Documentation

The key to ensuring accurate reimbursement for services

provided is understanding skilled coverage requirements


Questions/Answers


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