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Medical Review Is Back: Are You Ready to Respond to an ADR?

On March 30, the Centers for Medicare & Medicaid Services (CMS) suspended most Medicare fee-for-service (Part A and Part B) medical review audits as a result of the Coronavirus 2019 (COVID-19) public health emergency, including Targeted Probe and Educate (TPE) prepayment medical reviews conducted by Medicare Administrative Contractors (MACs), as well as postpayment reviews by the MACs, the Supplemental Medical Review Contractor (SMRC), and the Recovery Auditors (RAs) aka Recovery Audit Contractors (RACs). Note: See the box at the end of this article to learn which medical review contractor performs which type of audits—and what types of denials can occur.


However, in July, the agency announced its intention to resume medical review activities regardless of what happens with the public health emergency. Effective August 17, those activities started back up with MACs conducting postpayment medical reviews for items and services provided prior to March 1, 2020. Here is the relevant information excerpted and adapted from the August 6, 2020 MLN Connects eNews, the July 2020 COVID-19 Provider Burden Relief Frequently Asked Questions (FAQs), and CMS transmittal 10132:


To protect the Medicare Trust Fund against inappropriate payments, Medicare Administrative Contractors (MACs) are resuming fee-for-service medical review activities. Beginning August 17, the MACs are resuming with postpayment reviews of items/services provided before March 1, 2020. The Targeted Probe and Educate program (intensive education to assess provider compliance through up to three* rounds of review) will restart later. The MACs will continue to offer detailed review decisions and education as appropriate.


… If selected for review, providers should discuss with their contractor any COVID-19-related hardships they are experiencing that could affect audit response timeliness. CMS notes that all reviews will be conducted in accordance with statutory and regulatory provisions, as well as related billing and coding requirements. Waivers and flexibilities in place at the time of the dates of service of any claims potentially selected for review will also be applied. Note: Learn about applicable waivers and flexibilities here.



* Effective June 16, CMS has revised the language in chapter 3, “Verifying Potential Errors and Taking Corrective Actions,” of the Medicare Program Integrity Manual to clarify that more than three rounds of TPE review may occur. MACs refer providers that fail three rounds of TPE to CMS. That will result in the following next steps:


Once the MAC refers a provider/supplier to CMS, details are reviewed to determine if additional action must be taken by the MAC. Additional actions that may be required include, but are not limited to, additional rounds of TPE review, 100 percent prepayment review, extrapolation, referral to a Recovery Auditor, and/or referral for revocation. If CMS directs the MAC to conduct an additional round of TPE review, the MAC shall send the provider/supplier a notification letter indicating that an additional round of review is required. These reviews shall be of claims with dates of service at least 45 days after the prior round’s post-probe education and after the provider/supplier has received the aforementioned notification letter.


When Medicare auditors can’t make a determination on prepayment or postpayment claims review “based upon the information on the claim, its attachments, or the billing history found in claims processing system (if applicable) or the Common Working File (CWF),” they issue an additional documentation request (ADR) to solicit documentation from the provider, according to section, Time Frames for Submission, in chapter 3 of the Medicare Program Integrity Manual.


Providing documentation to support both a skilled level of care and the MDS coding that generated the Patient-Driven Payment Model (PDPM) HIPPS code billed on the Part A claim is crucial when responding to an ADR for medical review (or when making a redetermination request at the first level of appeal in response to a denial), says Maureen McCarthy, BS, RN, DNS-MT, QCP-MT, RAC-MT, RAC-MTA, president/CEO of Celtic Consulting in Torrington, CT.


Nurse assessment coordinators (NACs) can work with the interdisciplinary team to ensure that Medicare auditors receive the necessary documentation and mitigate the risk of a denial by taking the following steps:


Identify who will manage the ADR/denial process

“Someone in the facility should be assigned to manage all of the facility-level details in the ADR process and the denial process—from managing the notices to pulling the records together and sending them out timely to following up on the findings and determining whether to move to the next level of appeal,” says McCarthy. “Often, billers can do a good job taking on this organizational role, but it’s also important that NACs participate on the content side because they understand the skilled coverage rules and how the MDS and its supporting documentation feed into the billed HIPPS code.”


Look for documentation outside the medical record

“Sometimes the NAC has pieces of documentation that would support skilled services that may not be part of the permanent medical record,” notes McCarthy. “For example, when gathering data during the look-back period for the 5-day PPS MDS, the NAC may write a note in the MDS Notes section of the electronic medical record to explain an inconsistency in the documentation from the certified nursing assistants (CNAs) vs. the documentation from the unit nurses. However, the NAC never adds that MDS note as a progress note, and the staff member who pulls the medical record for an ADR doesn’t realize that that valuable note is still left in the system. NACs have to make sure that they provide the medical review auditor with all of the documentation that backs up the Medicare days under review.”


Follow the auditor’s rules and organize logically

When responding to an ADR or any denial based on a HIPPS code from a PPS MDS, Judy Wilhide Brandt, RN, BA, CPC, DNS-CT, QCP, RAC-MTA, president of Judy Wilhide MDS Consulting in Virginia Beach, VA, recommends taking the following three steps:

 1. Understand what the auditor is asking for, and give it to them. “This involves knowing how to read a request for records, understanding a UB-04 claim form, and knowing which elements on the MDS made up the HIPPS code,” says Brandt.

For an ADR, each contractor provides its own checklist of needed documentation, explains McCarthy. “Generally, these requests ask for the usual basic documentation to support a skilled level of care and the HIPPS code, such as nurse’s notes, CNA flow sheets, and physician orders.”
Note: See sample checklists here and here.


2. Arrange the record in a logical way for the reviewer. “Use cover sheets to show the elements of the HIPPS code,” suggests Brandt. “For example, for physical therapy (PT) and occupational therapy (OT), the reviewer will need to be able to verify the primary diagnosis and the function score.”


3. Put records that are requested but do not make up the HIPPS code at the very end of the chart. “Combine the records and use Bates numbering,” says Brandt. Note: Bates numbering is a commonly accepted method of assigning unique organizational identifiers to pages within each document in a set of related documents. Software programs such as Adobe offer this tool.


“Some Medicare auditors tell providers not to include the MDS in their submission packet because they can retrieve it from the national repository,” adds McCarthy. “However, if you move to the second level of the appeals process, the MDS doesn’t always get included in the packet if you didn’t submit it. Consequently, it’s a good idea to go ahead and add a copy of the MDS to your packet so that it’s there through every level of appeal.”


Respond timely

“One of the most common mistakes in responding to an ADR is missing the deadline for providing requested documentation because you didn’t give yourself enough time, especially when you sent your response package via the U.S. Postal Service’s snail mail. Making sure you get the records in timely is key,” says McCarthy. “In the past, some audit entities were willing to go beyond the deadline, while others made it a firm deadline. However, effective July 27, CMS has instructed all five types of Medicare auditors to deny claims on prepayment review or postpayment review for no response by the deadline, according to transmittal 10197.”


The following excerpt from section, Time Frames for Submission, in chapter 3 of the Medicare Program Integrity Manual explains:


A. Prepayment Review Time Frames

When requesting documentation for prepayment review, the MACs and UPICs shall notify providers when they expect documentation to be received. The reviewer should not grant extensions to providers who need more time to comply with the request. Reviewers shall deny claims when the requested documentation to support payment is not received by the expected timeframe.


B. Postpayment Review Time Frames

When requesting documentation for post-payment review, the MACs, CERT, SMRC, UPICs and RACs shall notify providers when they expect documentation to be received. MACs, CERT, SMRC, UPICs and RACs have the discretion to grant extensions to providers who need more time to comply with the request. The MACs, CERT, SMRC, UPICs and RACs shall deny claims when the requested documentation to support payment is not received by the expected timeframe (including any applicable extensions).


“Consequently, you need to be sure to meet those deadlines whether you are responding electronically, by fax, or by snail mail,” stresses McCarthy.


Double-check what you plan to submit

“Medical review auditors often cite information missing from the medical record, whether it is a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) or a physician certification, as the reason for a denial,” says McCarthy. “This is your opportunity to make sure that your I’s are dotted and your T’s are crossed. If you send clean documentation the first time around, you have a much better chance of saving that receivable.”


Therefore, once the staff member who is managing the ADR/denial process has gathered all of the information to be submitted to the Medicare auditor, the NAC or the Medicare nurse should read through it to make sure that it is appropriate and that no summary or addendum is required to clarify any information and wrap up the story of the patient, says McCarthy.


“If documentation is inadequate, you are allowed to provide a summary or addendum that reviews the resident’s clinical status when they were admitted, how and why you skilled them, what services you provided, their response to services, and what the outcome was,” she explains. “The medical reviewer may or may not accept this addendum to support the services. However, you can provide it. Just be sure not to back date your clarifying documentation. You want to make clear that you are referring back to that previous period.”


Understand that Medicare Advantage is different

“Medicare managed care plans not only follow a separate process for ADRs and denials, they also follow different coverage rules than traditional Medicare. In theory, the coverage rules are the same, but in practice, they aren’t,” says McCarthy. “Consequently, if you are appealing a Medicare Advantage or other Medicare managed care case, you need to be aware of the contract requirements for that specific payer you are dealing with to be able to appeal successfully.”



Medicare FFS Medical Review: Types of Claim Review and Types of Denials

Prepayment (before claim payment)

Postpayment (after claim payment)

Contractor Type

Medical Record Review

Non-Medical Record Review

Automated Reviews

Medical Record Review

Non-Medical Record Review

MACs Yes Yes Yes Yes Yes
CERT No No No Yes No
RAs/RACs No No No Yes No
SMRC No No No Yes Yes
UPIC Yes No No Yes Yes


Most of the claim review activities completed for the purpose of identifying inappropriate billing and avoiding improper payments are divided into three distinct types: Medical Record Review, Non-Medical Record Review, and Automated Review. The chart below indicates which contractors perform which types of review:


Medical reviewers can deny claims in part or in full: A partial denial is defined as either the disallowance of specific days within the stay or reclassification into a lower case-mix classifier. For any full or partial denials made, reviewers adjust the claim accordingly to recoup the overpayment. A partial denial based on classification into a new case-mix classification code or a full denial because the level-of care requirement was not met are considered reasonable and necessary denials (§1862(a)(1)(A)) and are subject to appeal rights.


Note: For information about how to make appeals, review chapter 29, “Appeals of Claims Decisions,” in the Medicare Claims Processing Manual and CMS’s Original Medicare (Fee-for-service) Appeals site, which is the launch pad to sites explaining all five levels of appeal in the standard appeals process, as well as providing access to the Medicare Learning Network how-to booklet, Medicare Parts A & B Appeals Process, and other resources. Also see the section, Medicare Appeals in Fee for Service (FFS), Medicare Advantage (MA) and Part D, in COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers.


Sources: Excerpted and adapted from (1) Section 3.3.1, Types of Review: Medical Record Review, Non-Medical Record Review, and Automated Review, in chapter 3, “Verifying Potential Errors and Taking Corrective Actions,” of the Medicare Program Integrity Manual, which will be updated via CMS transmittal 10228 effective August 27, 2020, and (2) Section 6.1.4, Medical Review Process/SNF PPS Claims, in chapter 6, “Medicare Contractor Medical Review Guidelines for Specific Services,” of the Medicare Program Integrity Manual.


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