We are barely out of the woods with the amount of national COVID-19 related deaths in the United States. We continue to work diligently to vaccinate residents and staff in our communities. Then, BAM! We are hit with an ADR (Additional Development Request) of twenty claims!…..[Sigh]
Preserving the Medicare Trust Fund is extremely important, as is identifying improper payments, and bringing those to justice who commit wrongdoing. But seriously! We are still dealing with staffing shortages, positive cases, and infection control. Now, we have the added burden of focused audits!
You probably already know that some Managed Care plans have been conducting 100% pre-payment audits; maybe you didn’t know? But, yes, One. Hundred. Percent! RAC audits are slowly ramping back up. TPE (Target Probe and Educate) Audits are still on hold per the MACs, but there are some ADR requests that appear a little “suspect” reflecting a medical review focusing on a certain CPT Code, like 97110 (Therapeutic Exercise), but it doesn’t say TPE. Yet it sure sounds a little like a TPE. This medical review ADR notification reads very similar to a TPE ADR notification, but some of the information is changed up a bit.
What is that saying people use…..?—“If it looks like a duck, and sounds like a duck, it’s a duck!” Is that how it goes?
Regardless of my rant, we have to respond to these ADRs, don’t we? Of course, we do! Even if we don’t like it, we have to go through it. Do you know what the number one reason for a denial is? The number one reason is, ‘No Documentation.’
According to CMS’ CERT Research and Statistics Data, there are five major error categories:
- No Documentation
- Provider fails to respond to repeated requests for medical records or the provider responds stating that they do not have the requested documentation to send. If you don’t want a denial, ensure you appropriately respond to the ADR.
- Insufficient Documentation
- The medical record documentation provided for review is inadequate to support the services billed for payment. Reviewers must come to the conclusion that the services billed were actually provided, provided at the level billed, and were medically necessary. This category also includes certain documents required for payment, such as a physician signed order, a physician recert/recert completely filled out and signed/dated by physician, etc.
- Medical Necessity
- If the reviewer determines that the documentation in the medical records lack supporting entries reflecting the services were medically necessary in accordance with Medicare coverage and payment policies.
- Incorrect Coding
- Occurs when the documentation provided reflects: 1) A different code than what was billed; 2) The services were performed by someone other than the billing provider; 3) The services billed were unbundled; or 4) When the patient was discharged to a site other than the site coded on the claim.
- Other- for claims that do not fit in the above four categories.
Get ahead of your audit risks!
Watch for ADR Notifications. Regardless if you conduct your billing in-house or through a third party billing company, the billing provider is ultimately responsible for ensuring they respond to ADRs. Ensure all who are involved in billing claims communicate ADRs immediately with you and act promptly to the request. It takes time to collect all necessary documentation that affects the dates under review and time is needed to review the documentation to ensure everything is included in the ADR packet.
Audit, Train, and Audit Again and Again. Documentation is a critical lifeline for survival from audits, even PDPM audits. PDPM audits have been non-existent due to COVID-19 and the PHE (Public Health Emergency), but soon, they will be here. The time to ensure your documentation will stand up against an audit is now! Therapy documentation should not be your only focus. More importantly, Nursing documentation to support the Nursing and NTA components of the PDPM system is an area where providers need to work on. If something is coded on the MDS, you should be able to find proof in the medical record to support what is coded on the MDS. If you cannot find it, you shouldn’t be coding it on the MDS. Same for other payer types. If you are billing for it, you should be able to find supporting documentation in the medical record. Look at your documentation, billing, and coding practices without blinders on. Government auditors will not hold anything back, so why should you?
Plan. There is nothing worse than not having a plan when faced with an audit. Consider an Appeal Team. Consider adding an internal auditing plan and hold yourself accountable through reporting in your QAPI meeting. Educate and train key employees who are responsible for the medical record entries. Help them by providing tools to improve documentation quality. Ask for an outside auditor to review your documentation, billing, and coding practices. It’s a much better situation to identify issues and correct them before a government auditor does.
Functional Pathways can help with your auditing efforts. Contact consulting@fprehab.com for more information.
Gina Elkins, CHC, OHCC, RAC-CT, LPTA, Senior Director of Compliance and Regulatory Strategy