Home Health & Hospice Week

You should check for ADR'd claims daily.

With medical review from government contractors and agencies on the rise, you need to get your ADR basics down pat.

You can't get much more basic than responding to an additional development request (ADR). Yet lack of response to an ADR is the number- two denial reason for home health agencies and the number-four denial reason for hospices in Palmetto GBA's third quarter, the HHH Medicare Administrative Contractor reveals in its December provider newsletter.

That reflects what reimbursement consultant M. Aaron Little is seeing in the field. "I continue to find agencies with personnel who don't know how to identify that a claim has been selected for medical review," Little tells Eli.

Use these tips to combat this common reason for HHA and hospice denials:

1. Monitor for ADRs. You should monitor for ADR'd claims in the Direct Data Entry (DDE) system, Palmetto urges. "If the claim is in status/location SB6001, the claim has been selected for review and records must be submitted," the HHH MAC explains.

Details: "One of the easiest ways to check is to look in DDE Option 56 for any claims in the status of S B6001," says Little, with BKD in Springfield, Mo. "If there are no claims in that status, then there are no ADRs."

When you do find claims in that status, "then the next step is to go into DDE Option 12 and look up the specific claims in S B6001," Little continues. "This area will provide not only the specific claims selected for review, but also will indicate when the information needs to be received, what information needs to be received, and where the information needs to be mailed."

You should check for ADRs frequently, Little urges. "It's critical that billing personnel check for ADRs routinely, no less than weekly, but ideally a quick check each day."

Snail mail: Palmetto will also send you a paper letter with the ADR, the MAC says. Staff should look for them in a standard white envelope with a Palmetto return address.

2. Observe the deadline. "Be aware of the need to submit medical records within 30 days of the ADR date," Palmetto stresses. If you wait to receive the paper letter, that cuts that much more time off the response window. "The ADR date is in the upper left corner of the ADR request," Palmetto points out.

Watch out: "If the requested documentation is not received timely, the claim will be automatically denied on day 46," HHH MAC CGS says in its December bulletin for providers.

3. Prepare the ADR response. You should have a procedure for notifying clinical or agencyleadership as soon as possible after learning of the ADR, Little recommends. That gives them maximum time to prepare a response.

"Review chart documentation prior to sending," CGS recommends in its Quick Response Tool for ADRs. "Ensure documentation [is] complete and supports all services/level of care billed."

Tip #1: When you want to bring reviewers' attention to portions of the record, don't use a highlighter, CGS cautions in the bulletin. "The text becomes obscured when viewing online," the MAC explains.

Instead, use brackets, asterisks, or underlining to draw attention to the relevant passages, CGS  suggests. "However, providers should be careful notto add marks that alter, or appear to alter, the documentation."

Tip #2: Experts recommend using a cover letter to summarize the record and explain how the patient meets Medicare coverage criteria. Such letters often are "useful to inform the Medical Review staff of specific information, and where it can be found in the documentation," CGS notes. "However, information in the cover letter must be supported in the medical record in order to be considered in the review and determination of the claim," the MAC cautions.

4. Keep it together. "Gather all information needed for the claim and submit it all at one time," Palmetto instructs.

You should include a screen print-out of p. 07 of the claim, CGS recommends. "This will help to ensure that the information is identified as ADR documentation for medical review."

5. Separate multiple ADRs. "If responding to multiple ADRs, separate each response and attach a copy of the ADR to each individual set of medical records," Palmetto advises. "Ensure each set of medical records is bound securely so the submitted documentation is not detached or lost."

CGS recommends a more drastic approach to keep ADRs separate. "We strongly suggest that documentation for each claim be mailed in a separate envelope," CGS says. "This will avoid any risk of having documentation scanned as one record, rather than separate records, which could result in a claim being denied inappropriately."

6. Send it to the right place. "Return the medical records to the address on the ADR," Palmetto instructs. "Be sure to include the appropriate mail code. This ensures your responses are promptly routed to the appropriate department that requested the records."

Sending it to the correct address might be more confusing for agencies served by CGS, since it switched mailing addresses on Dec. 5. The old address was in Chattanooga, Tenn.; the new address is in Nashville.

Remember not to send ADR responses COD, because MACs can't accept them, Palmetto says.

7. Keep tabs on ADRs. Your job isn't done once the ADR response is filed. "Billing personnel can keep track of those claims by continuing to track them in DDE Option 12," Little explains. Use that option to monitor as the claims move into new status locations. Status locations beginning with "MR" indicate movement of a claim through medical review, so look for locations such as those labeled as "S MRxxx," Little advises.

8. Appeals may be worth your while. Eventually ADR'd claims will either be paid, partially paid, or denied, Little notes. "For those claims that are only partially paid or fully denied, the billing/payment posting personnel need to communicate to clinical and/or agency leadership so that it can be determined whether or not to appeal the claim."

Claims denied for homebound status or medical necessity often are overturned at the first appeal level, Little points out. "Unless the documentation clearly doesn't support the claim, then we typically suggest the claims be carried through at least the request for reconsideration process," he says.