In nursing facilities, one of the primary regulatory requirements from Appendix PP of the State Operations Manual is that goods and services are provided to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident (§483.24 Quality of Life). One intervention frequently used is Medicare Part B therapy. This may be used following an event, such as a fall due to a new balance problem, as a result of a gradual decline in functional ability, or even when an improvement in function or cognition would allow for new goals to be established. Each time Part B therapy is provided, the facility staff must ensure all elements of billing requirements are met, since there could be an audit or additional documentation request (ADR) submitted for the claim. Here are four key things you can do to be successful during a Part B ADR:
Coordinate responsibility
When responding to an ADR, it is key to have a point-person in charge of reviewing and delegating the collection of information to appropriate team members. “Make sure you know who is responsible in the facility for receiving and reviewing any request for information. If that person is on vacation or out of the office, be sure there is a backup process,” stresses Liz Barlow, RN, CRRN, RAC-CT, DNS-CT, AVP of clinical innovations at Synchrony Rehab.
However, it is also critical to have the right team members involved. Barlow recommends to “include the business office manager and biller in the facility in the process, as they are the ones who most likely will receive the request. The therapy manager or program director will then need to be aware of the request so that appropriate documents can be reviewed and pulled. I also think it is important to have a nurse representative who can help to review the documentation packet prior to submission. This can be a unit manager, assistant director of nursing, or director of nursing.”
The point-person must monitor deadlines, Barlow emphasizes. “There are time frames associated with these types of requests, and each day matters. Failure to respond by the deadlines will not have good results. The biggest risk is that if the information isn’t submitted timely, then all of the claims will automatically be denied. It is important to have a strong process in place for retrieving and reviewing the information.”
Know what to include
The ADR point-person needs to carefully review the request and ensure that the response includes all required documentation. Barlow clarifies, “Be sure to include the physician-signed therapy evaluation, progress reports, and any daily notes and billing logs associated with the time frame. Many people think that if the request is for the month of April, for example, that only April information should be included. But if the evaluation is completed in March, that is relevant information to include to a reviewer.”
It is also important to identify additional documentation that may help to support the claim, says Barlow. “For example, if your software shows outcomes, share outcomes data and graphs for that resident.” Barlow stresses that the team must look beyond therapy notes, “Nurses’ progress notes that reflect the change in function or reason for picking the patient up on caseload is also incredibly beneficial.”
The point-person must also be aware of additional risks when including information for ADR responses, “For example,” explains Barlow, one outcome to avoid is if “a reviewer sees some type of negative trend within the documents submitted, and then wants to start reviewing more claims.”
Know why the ADR was received
There are many reasons a facility might receive an ADR. To be successful with the request, the team must understand why it was received. Some denials may be due to a Local Coverage Determination (LCD) which is unique to each Medicare Administrative Contractor (MAC), says Barlow. “Some MACs will deny a modality, for example, that another MAC would pay for, based on the LCD alone.” Understanding why the request was received will help guide the process the team uses to collect and submit information.
Facilities may also receive ADRs because they have a high denial rate, adds Barlow. “Responding to ADRs takes a lot of time and resources, so we always want the process to go smoothly and for claims to be paid appropriately.” When teams retrieve and review information for an ADR, it also allows them to spot gaps in processes or in documentation. The team must use this as an opportunity to improve the facility’s process, potentially utilizing a QAPI plan to ensure these gaps are resolved and avoiding future audits.
Tell the story
When responding to the ADR, make the information organized and easy to read. “Put the medical record together in a PDF packet or paper packet that tells the chronological story,” says Barlow. “If the information submitted is not in neat order, a reviewer isn’t going to waste his or her time in trying to review the information.” This could result in a claim denial, since the requested information was not well-presented.
In addition, AAPACN’s Responding to ADRs tool recommends that each packet should be reviewed to ensure that:
- Content is appropriate
- All documents are legible
- Signatures, credentials, and dates are in place
- Attestation statements are gathered, if needed
- Duplicates are removed
- Staples are removed
- Documentation is on only one page of each document
- Pages are numbered (lower right-hand corner)
- A copy of what is sent to the reviewer is maintained
- Original documents are placed back in the medical record
- Mailing instructions are followed exactly
Note: The AAPACN tool Responding to ADRs focuses on Medicare Part A audits, but contains information and tips that can also be applied to Part B audits.
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