HOW TO WRITE AN APPEAL LETTER

Transcription

1 HOW TO WRITE AN APPEAL LETTER for clients of: Content developed and presented by: 3030 N. Rocky Point Drive, Suite 240 Tampa, FL

2 How to Write an Appeal Letter Limited Copyright: October 2017, Polaris Group All materials are protected under the copyright laws. The limited copyright allows the purchaser to copy for use but not for distribution. FH61 - Developed by Polaris Group Page 1 of 57

3 How to Write an Appeal Letter POST TEST 1. The goal of medical review is to reduce payment error by identifying and addressing billing errors. a. True b. False 2. The four appeal levels include Redetermination, Reconsideration, Appeals Council Review and Judicial Review in U.S. District Court. a. True b. False 3. The appeal letter presents an opportunity to describe and justify the skilled services that could only be provided in the skilled nursing facility as well as the RUG score billed. a. True b. False 4. One way to determine whether to appeal or not is to create a decision tree. a. True b. False 5. There is only one way to write an appeal letter. a. True b. False FH61 - Developed by Polaris Group Page 2 of 57

4 How to Write an Appeal Letter POST TEST ANSWERS 1. The goal of medical review is to reduce payment error by identifying and addressing billing errors. A a. True b. False 2. The four appeal levels include Redetermination, Reconsideration, Appeals Council Review and Judicial Review in U.S. District Court. B a. True b. False 3. The appeal letter presents an opportunity to describe and justify the skilled services that could only be provided in the skilled nursing facility as well as the RUG score billed. a. True A b. False 4. One way to determine whether to appeal or not is to create a decision tree. a. True A b. False 5. There is only one way to write an appeal letter. a. True B b. False FH61 - Developed by Polaris Group Page 3 of 57

5 Writing an Effective Appeal Letter 1 Content Medical Review The 5 Levels of Appeals Brief review of common reasons for Denials Responding to ADR - Compiling Medical Records Determining whether to Appeal or Not Writing an effective Appeals Letter 2 FH61 - Developed by Polaris Group Page 4 of 57

6 MEDICAL REVIEW 3 Medical Review The goal of medical review is to reduce payment errors by identifying and addressing billing errors. Medical review decisions are based on documentation provided to the intermediary to support medical necessity of the services provided to the beneficiary. Medical denial decisions must be based on a detailed and thorough analysis of the beneficiary s total condition and individual need for care. Unless medical justification for the level of care and the necessity of such services is documented in the medical record, benefits are denied. 4 FH61 - Developed by Polaris Group Page 5 of 57

7 Medical Review Key elements for successful medical review: Implement policy and procedure guidelines in place for complying with medical review requests: Responsible person(s) Tracking system Quality Assurance Recognize Medicare Claim Review Programs and Types of Contractors Understand the Levels of Appeal 5 Medical Review Key elements for successful medical review: Review each case individually and prioritize claims based on level of risk and dollar amount. Know the Medicare Guidelines. Submit an Appeal Letter at every step of the appeal process including Additional Development Requests (ADR). 6 FH61 - Developed by Polaris Group Page 6 of 57

8 Medical Review Tracking System When the ADR or denial was received When the packet is due to the intermediary When the record was sent out Amount in controversy Reason for denial 7 APPEAL LEVELS 8 FH61 - Developed by Polaris Group Page 7 of 57

9 Appeals Levels 1 st Level 2 nd Level 3 rd Level Redetermination Reconsideration Administrative Law Judge (ALJ) 120 days to file Amount in Controversy (AIC) = $0 180 days to file AIC = $0 60 days to file AIC = $160* 4 th Level Medicare Appeals Council 5 th Level Final Judicial Review 60 days to file AIC = $0 60 days to file AIC = $1,560* *2017 AIC 9 1 st Level - Redeterminations Recommend using CMS form Providers may appeal for any reason Appointment of representative form not required Contractor decision No Acknowledgement Letters Medicare Redetermination Notice (MRN) 10 FH61 - Developed by Polaris Group Page 8 of 57

10 2 nd Level - Reconsiderations Recommend using CMS form QIC jurisdiction Independent Facility Chain Providers QIC file request QIC decision Contractors decision 11 3rd Level - Administrative Law Judge Provider time-frame Where to submit request New evidence-requires Good Cause AIC Video Telephone Conference Decision time-frame Delay causes 12 FH61 - Developed by Polaris Group Page 9 of 57

11 4th and 5th Levels of Appeal 4 th - Medicare Appeals Council Review No Amount in Controversy requirement Contractors decision 5 th - Federal District Court Provider has 60 days from notice of nonfavorable Council decision to request Amount in Controversy (AIC)* * set annually 13 COMMON DENIALS 14 FH61 - Developed by Polaris Group Page 10 of 57

12 Review of Common Denial Reasons No valid order Services did not require skilled therapy Use of appropriate HCPCS codes The amount, frequency and duration of services were not reasonable, given the patient s current status Documentation in the medical record was conflicting indicating no improvement. 15 Common Reasons for Denial Skilled therapy was provided when non-skilled maintenance services would have been more appropriate. Documentation did not support the patient s functional level had changed when compared to the prior level of function. Therapy set unrealistic goals given the prior level of function. 16 FH61 - Developed by Polaris Group Page 11 of 57

13 Medicare Claim Review Programs Type of CERT Error No Documentation Insufficient Documentation Medical Necessity Incorrect Coding Other Description Provider fails to respond to requests for documentation Submitted documentation is inadequate to support payment for the services billed There is adequate documentation in the medical record to make the informed decision that the services billed were not medically necessary Medical documentation supports a different code than what was billed, the billed services was unbundled or beneficiary was discharged to a site other than the one on a claim Error does not fit into other categories 17 RESPONDING TO ADRS - COMPILING MEDICAL RECORD 18 FH61 - Developed by Polaris Group Page 12 of 57

14 Responding to ADRs Compile the medical record and make sure all the requested information is submitted. 1. Read the entire request 2. Identify the reason for the request 3. Note the beneficiary name and dates of service 4. Gather ALL of the requested portions of the medical record including a full look-back period for all MDS assessments included in the claim. Utilize a documentation checklist 19 Responding to ADRs Compile the medical record 1. Collect any additional information that may support the claim 2. Verify the beneficiary name is included on each page of the medical record 3. Number each page of the record on the lower right hand side of the page 4. Copy all collected documentation 20 FH61 - Developed by Polaris Group Page 13 of 57

15 Responding to ADRs Compile the medical record 1. Review all materials AFTER copying 2. Validate the documentation is for the dates of service and the beneficiary requested 3. Validate the documentation matches and supports the services submitted on the claim. 21 Responding to ADRs If the Intermediary does not believe that your documentation meets their criteria for payment, you will receive notification that the claim was denied 22 FH61 - Developed by Polaris Group Page 14 of 57

16 DETERMINING WHETHER TO APPEAL OR NOT 23 Determining to Appeal or Not Create a Decision Tree for determining cases to appeal technical issues Develop a workflow process who, what, when for making the decision to appeal coding or clinical issues Define an appeal methodology timing is everything Begin developing a library of appeal letter templates and documents for appeal 24 FH61 - Developed by Polaris Group Page 15 of 57

17 APPEAL LETTER 25 Appeal Letter Review the decision letters (results letter and demand letter) in detail Decision letters include: Regulations used in the decision to deny Reason for denial Instructions for appeal Required forms or required information Timelines and addresses 26 FH61 - Developed by Polaris Group Page 16 of 57

18 Appeal Letter Review and Follow the Instructions for Appeal- Example: To avoid recoupment the appeal must be filed within XX days of this letter. We request that you clearly indicate on your appeal request that this is a XX overpayment appeal and you are requesting a redetermination. Send your appeal request with a copy of this entire letter to: XX 27 Appeal Letter Make it easy for the decision-maker to find in your favor. All of the contractors are facing a backlog of cases, and it is possible that the key facts in your case will get lost in the shuffle if you do not point them out clearly to the reviewer. Make it easy for the reviewer by organizing the medical record in a coherent fashion and making key documentation easy to find. 28 FH61 - Developed by Polaris Group Page 17 of 57

19 Appeal Letter Denials can sometimes result from the contractor failing to see a document in the medical record. Attaching key documentation as a separate exhibit, or pointing out where it can be found in the medical record, can help minimize these issues. 29 Appeal Letter Sections HEADING RESIDENT IDENTIFICATION ISSUE RESPONSE TO DENIAL FACTS OF CASE PRIOR LEVEL OF FUNCTION TREATMENT PLAN FACTS FOR SERVICES RENDERED 30 FH61 - Developed by Polaris Group Page 18 of 57

20 Appeal Letter Sections DOCTORS AUTHORIZATION EVALUATION TREATMENT PLAN RESULTS RULE CONCLUSION SIGNATURE WITH CREDENTIALS 31 Heading of Letter Date: XX/XX/XXXX To: From: Name including credentials Facility Name: Provider #: 32 FH61 - Developed by Polaris Group Page 19 of 57

21 Heading of Letter Subject: Denial of Medicare services for XX HIC# Dates of Service: Dates Denied or Downcoded: Type of Service: Physical and/or Occupational Therapy, etc 33 Appeal Letter Introduction The above referenced claim has been selected for an Additional Development Request. Along with the requested documentation, we are including this letter which summarizes the skilled services provided to the beneficiary as required by the Medicare Benefit Policy Manual. For your convenience, the pages of the medical record are numbered and circled in the lower right hand corner of each page. 34 FH61 - Developed by Polaris Group Page 20 of 57

22 Resident Identification Hospital information Reason for admission into hospital Diagnosis Procedures Reason for SNF admission Therapy Nursing Practical Matter Paint the Picture 35 Resident Identification Example: Exhibit A Overview of Hospitalization Admission Initial SNF Admission 36 FH61 - Developed by Polaris Group Page 21 of 57

23 Issue Build your foundation for your appeal Identify the audit rationale for denial Exhibit B We have received notice that Medicare payment for Skilled Nursing Facility services has been denied for the above noted period. The reason for the denial was stated as, xxx. 37 Issue Issue identified in letter - Example: We would like to request a reconsideration of the denial of skilled services for the above claim dates. The unfavorable decision was stated as: 1) The services were routine and did not warrant the continued skills of a licensed therapist. In conclusion, in accordance with CMS IOM, Publication 100-8, Medicare Program Integrity Manual, Chapter 6, Section 6.1.3, the services provided April 1, 20XX, through April 30, 20XX were reviewed and the documentation did not support that all of the services provided were skilled services 38 FH61 - Developed by Polaris Group Page 22 of 57

24 Response To Denial Examples: We disagree with this denial and respectfully request reconsideration due to the evidence cited below. These denial reasons will be addressed below, and the documentation provided supports that the skills of qualified therapist were necessary to provide the services including gait training, balance training, bed mobility training and self care training. Skilled interventions included teaching/training of proper techniques and adding challenges/upgrading goals as the beneficiary improved. 39 Facts of the Case Beneficiary s condition(s) that required and/or contributed to the need for said services XX was referred to rehabilitation therapy due to a significant functional decline following hospitalization XX for XX. He was a high risk for re-hospitalization and therapy services were a key factor in preventing this both during and after his stay at XX. 40 FH61 - Developed by Polaris Group Page 23 of 57

25 Example: Facts of the Case The following is a synopsis of care and services provided to the above beneficiary with additional supportive statements and clarification for the billing of therapy services resulting in Rehab RUGs being billed. Services were skilled, plan of care was adjusted daily and was not routine and finally were medically necessary to progress this patient to his highest level of function. 41 Prior Level of Function Prior to the decline in functional status, the patient was Status of functional abilities prior to the condition causing the need for rehabilitation services the level of function prior to the hospitalization Show detailed picture of functional status including any role they provided at home. 42 FH61 - Developed by Polaris Group Page 24 of 57

26 Prior Level of Function - Examples Patient lives in an assisted living facility. They were independent with bathing, toileting, grooming and ambulating without assistive device. Patient lives with elderly spouse in two story home with bedroom on second floor. Patient is primary caregiver to spouse and was independent with bathing, toileting, grooming but ambulated with assistive device. She/He navigated steps to second floor without assistance. She/He independently completed all shopping, cooking and laundry. 43 Treatment Plan The treatment plan for physical therapy included therapeutic activities, neuromuscular reeducation, w/c management, gait training, and therapeutic exercise. The treatment plan for occupational therapy included self care retraining, neuromuscular reeducation, therapeutic activities, and therapeutic exercise. 44 FH61 - Developed by Polaris Group Page 25 of 57

27 Facts for Services Rendered Facts that indicated a reasonable expectation for significant improvement if services were rendered: Prognosis for achievement of goals was good due to the patient s prior level of function, recent onset of difficulties, ability to participate in treatment tasks, and good motivation to return to prior functional level. Indications why a reasonable expectation for significant improvement was expected 45 Facts for Services Rendered Include any deficits that delayed progress: Pain Cognition Depression Multiple Co-morbities 46 FH61 - Developed by Polaris Group Page 26 of 57

28 Doctors Authorization Identify services in controversy Examples: There was not a valid order for provision of XX therapy treatment 6 days a week. Speech therapy service were routine in nature and did not require the skills of a licensed professional Physician certification was not dated 47 Evaluation The evaluations on XX revealed the following deficits: Physical Therapy SKILLED AREA MEASUREMENT ROLLING SIT TO SUPINE SIT TO STAND BED AND TOILET TRANSFER GAIT 48 FH61 - Developed by Polaris Group Page 27 of 57

29 Evaluation The evaluations on XX revealed the following deficits: Occupational Therapy SKILLED AREA MEASUREMENT SELF FEEDING GROOMING UPPER BODY SAFETY JUDGEMENT COGNITION 49 Treatment Plan Results If denial was based upon whether skilled services were reasonable and necessary specify why were needed. The treatment plans were developed as stated above and approved by the patient s physician. During the visits in question of XX, the patient made the following progress 50 FH61 - Developed by Polaris Group Page 28 of 57

30 Treatment Plan Results The beneficiary was evaluated by physical therapy on 8/28/20XX. Beneficiary demonstrated good rehab potential based on the demonstrated functional decline, a plan of care was established to address the below performance areas, with progress as noted below: SKILL AREA ROLLING SIT TO SUPINE SIT TO STAND BEGINNING OF BILLING PERIOD END OF BILLING PERIOD BED AND TOILET TRANSFER 51 Supporting Documents The provider should submit all supporting documents at the first or second level of the appeals process (must be submitted prior to second level final determination) These documents could include: Training guidelines for certain disciplines Positions of national organizations Decisions or directives from CMS Identify the Medicare criteria that support payment of the claim 52 FH61 - Developed by Polaris Group Page 29 of 57

31 Rule Identify the Medicare coverage guideline citations that support coverage of this claim. Use payment and reimbursement guidelines, evidence-based clinical practice guidelines, and judicial law citations in appeal letter Become a winning appeals writer by doing the research 53 Rule Review the Regulations Used in the Decision to Deny Following all the Leads Excerpt from a Review Results Letter Download and save the sections referenced in the determination letter Maintain an Appeals Documentation library. 54 FH61 - Developed by Polaris Group Page 30 of 57

32 Rule Medicare #1861of the Act* Medicare #1879 of the Act* Medicare #1870 of he Act* *Social Security Act 55 Rule Medicare Benefit Policy Manual, Chapter 8 Reasonable and necessary Necessary to improve the patient s condition, maintain the patient s condition or slow further deterioration Provided daily MD ordered As a practical matter, can only be provided in the skilled nursing facility 56 FH61 - Developed by Polaris Group Page 31 of 57

33 Rule Medicare Benefit Policy Manual, Chapter 8 Patient requires skilled nursing or rehabilitation services Requires the skills of qualified technical or professional health personnel. Must be provided directly by or under the general supervision of these skilled nursing or skilled rehabilitation personnel. The inherent complexity of a service is such that it can only be safely & effectively performed by skilled nursing or rehabilitation personnel. 57 Rule Medicare Benefit Policy Manual, Chapter 8 Specific examples of skilled nursing or rehabilitation services Management and evaluation of a patient care plan Observation and assessment of patient s condition Teaching and training activities Direct skilled services to patients 58 FH61 - Developed by Polaris Group Page 32 of 57

34 Rule Medicare Benefit Policy Manual, Chapter 8 Medical record is expected to provide important communication among all members of the care team regarding the development, course and outcomes of the skilled services provided History and physical exam pertinent to the patient s care Skilled services provided Patient s response to the skilled services Plan for future care based on rationale of prior results 59 Rule Medicare Benefit Policy Manual, Chapter 8 Medical record, continued A detailed rationale that explains the need for skilled service in light of the patient s overall medical condition and experiences The complexity of the services to be performed Any other pertinent characteristics of the beneficiary 60 FH61 - Developed by Polaris Group Page 33 of 57

35 Rule Medicare Benefit Policy Manual, Chapter 15 Reasonable and necessary Necessary to improve a patient s current condition, to maintain a patient s current condition or to prevent or slow further deterioration Of a complexity and sophistication or the condition of the patient shall be such that the services required can be safely and effectively performed only by a therapist or under supervision of a therapist 61 Rule Medicare Benefit Policy Manual, Chapter 15 Skills of the therapist are needed to treat the illness or injury Skilled procedures include but are not limited to Evaluations Establishment of treatment goals specific to the patient s disability or dysfunction and designed to specifically address each problem identified in the evaluation 62 FH61 - Developed by Polaris Group Page 34 of 57

36 Appeal Conclusion Summarize why services provided were necessary and why Medicare should pay for them. We respectfully submit the above information for review and request overturn of the denial of the services for the claim in question. Examples: The skills of qualified therapists were necessary to provide the services including gait training, balance training, bed mobility training, and self care training. 63 Appeal Conclusion Additional Examples: Based on evaluation results, the therapist had reasonable expectation of improvement for this patient with skilled intervention. The expectation of improvement was based on the patient s prior level of function, A & O x 3 cognition, and documented progress during the billing period. 64 FH61 - Developed by Polaris Group Page 35 of 57

37 Additional Examples: Appeal Conclusion Significant gains in targeted areas resulted from skilled intervention. The patient improved in gait, bed mobility, balance, self care, and transfers. The patient only experienced these benefits as a result of skilled intervention by qualified physical and occupational therapists. Skilled intervention included teaching proper technique and adding challenges/upgrading goals as the patient improved. 65 Appeal Conclusion Additional Examples: We believe the services provided were reasonable for the patient and were in compliance with Medicare coverage guidelines. We believe the evaluation and treatment provided to XX were medically necessary for the patient s condition and feel strongly that the patient would not have experienced the same functional gains with nursing care in the absence of skilled physical and occupational therapy. 66 FH61 - Developed by Polaris Group Page 36 of 57

38 Appeal Conclusion Should tell Medicare why you disagree with their decision and always thank them for their reconsideration Thank you for your reconsideration in the denial of services for this beneficiary. We feel very strongly that this beneficiary required skilled nursing and rehabilitation services to enable the highest level of independence for improved quality of life. Sign and include your credentials 67 Questions?? 68 FH61 - Developed by Polaris Group Page 37 of 57

39 Date: XX/XX/XXXX To: From: Name including credentials Facility Name Provider #: Subject: Denial of Medicare services for HIC# Dates of Service: Dates Denied/Downcoded: Type of Service: Physical and Occupational Therapy, etc 1- Issue We have received notice that Medicare payment for Skilled Nursing Facility services has been denied for the above noted period. The reason for the denial was stated as, xxx. 2- Response to Denial We disagree with this denial and respectfully request reconsideration due to the evidence cited below. 3- Facts of the Case Beneficiary s condition(s) that required and/or contributed to the need for said services Mx was referred to rehabilitation therapy due to a significant functional decline following hospitalization xx for xx. Prior Level of Function Prior to hxx decline in functional status, the patient was Treatment plan The treatment plan for physical therapy included therapeutic activities, neuromuscular re-education, w/c management, gait training, and therapeutic exercise. For occupational therapy the treatment plan included self care retraining, neuromuscular reeducation, therapeutic activities, and therapeutic exercise. Facts that indicated a reasonable expectation for significant improvement if services were rendered: Prognosis for achievement of goals was good due to the patient s prior level of function, recent onset of difficulties, ability to participate in treatment tasks, and good motivation to return to prior functional level. Doctor s authorization for services in controversy Evaluation Results FH61 FH03a - Developed - Developed by Polaris by Polaris Group Group Page Page 27 of 38 31of 57

40 The evaluations on xx revealed the following deficits: Skill area Measurement Physical therapy Rolling Sit <> supine Sit to stand Bed and toilet transfers Sitting balance (S/D) Standing balance (S/D) BLE strength Gait Sensorimotor Neuromotor Occupational therapy Self feeding Grooming UB dressing LB dressing Toileting hygiene Toileting clothing management Toilet transfer UB bathing LB bathing Functional mobility Safety judgment Activity tolerance UB strength Cognition ROM Balance for seated ADLs Balance for standing ADLs Results of treatment plan The treatment plans were developed as stated above and approved by the patient s physician. During the visits in question of xx, the patient made the following progress: Skill area Beginning of billing period End of billing period Physical therapy Rolling Sit <> supine Sit to stand Bed and toilet transfers Sitting balance (S/D) Standing balance (S/D) BLE strength Gait Sensorimotor Neuromotor Occupational therapy Self feeding FH61 FH03a - Developed - Developed by Polaris by Polaris Group Group Page Page 28 of 39 31of 57

41 Grooming UB dressing LB dressing Toileting hygiene Toileting clothing management Toilet transfer UB bathing LB bathing Functional mobility Safety judgment Activity tolerance UB strength Cognition ROM Balance for seated ADLs Balance for standing ADLs Treatment continued If denial was based upon whether skilled services were reasonable and necessary specify why were needed: 4- Rule The following Medicare coverage guideline citations support coverage of this claim. SAMPLE RULES must modify to pertinent, current regulatory statement Skilled Nursing Facility Manual. Chapter Direct Skilled Rehabilitation Services to Patients A. Skilled Physical Therapy. Example 1: An 80-year-old, previously ambulatory, post-surgical patient has been bed bound for one week and, as a result, has developed muscle atrophy, orthostatic hypotension, joint stiffness and lower extremity edema. To the extent that the patient requires a brief period of daily skilled physical therapy services to restore lost functions, those services are reasonable and necessary. Skilled Nursing Facility Manual. Chapter Physical, Speech, and Occupational Therapy Furnished by the Skilled Nursing Facility or by Others under Arrangements with the Facility and under its Supervision.--Physical Therapy. 2. Reasonable and Necessary.--To be considered reasonable and necessary the following conditions must be met: The services must be considered under accepted standards of medical practice to be a specific and effective treatment for the patient's condition, The services must be of such a level of complexity and sophistication or the condition of the patient must be such that the services required can be safely and effectively performed only by a qualified physical therapist or under his supervision, There must be an expectation that the condition will improve significantly in a reasonable (and generally predictable) period of time based on the assessment made by the physician of the patient's restoration potential after any needed consultation with the qualified physical therapist or the services must be necessary to the establishment of a safe and effective maintenance program required in connection with a specific disease state, and The amount, frequency, and duration of the services must be reasonable. Skilled Nursing Facility Manual. Chapter Direct Skilled Rehabilitation Services to Patients. C. Occupational Therapy.--General.--Occupational therapy is medically prescribed treatment concerned with improving or restoring functions which have been impaired by illness or injury or, where function has been FH61 FH03a - Developed - Developed by Polaris by Polaris Group Group Page Page 29 of 40 31of 57

42 permanently lost or reduced by illness or injury, to improve the individual's ability to perform those tasks required for independent functioning. Such therapy may involve: The evaluation, and reevaluation as required, of a patient's level of function by administering diagnostic and prognostic tests; The selection and teaching of task-oriented therapeutic activities designed to restore physical function, e.g., use of wood-working activities on an inclined table to restore shoulder, elbow and wrist range of motion lost as a result of burns; The planning, implementing, and supervising of individualized therapeutic activity programs as part of an overall "active treatment" program for a patient with a diagnosed psychiatric illness, e.g., the use of sewing activities which require following a pattern to reduce confusion and restore reality orientation in a schizophrenic patient; The planning and implementing of therapeutic tasks and activities to restore sensory-integrative function, e.g., providing motor and tactile activities to increase sensory input and improve response for a stroke patient with functional loss resulting in a distorted body image; The teaching of compensatory technique to improve the level of independence in the activities of daily living, for example: Teaching a patient who has lost the use of an arm how to pare potatoes and chop vegetables with one hand. Teaching an upper extremity amputee how to functionally utilize prosthesis. Teaching stroke patient new techniques to enable him to perform feeding, dressing and other activities as independently as possible. Teaching hip fracture/hip replacement patient techniques of standing tolerance and balance to enable him or her to perform such functional activities as dressing and homemaking tasks. The designing, fabricating, and fitting of orthotic and self-help devices, e.g., making a hand splint for a patient with rheumatoid arthritis to maintain the hand in a functional position or constructing a device which would enable an individual to hold a utensil and feed himself independently; and Vocational and prevocational assessment and training. Only a qualified occupational therapist has the knowledge, training, and experience required to evaluate and, as necessary, reevaluate a patient's level of function, determine whether an occupational therapy program could reasonably be expected to improve, restore, or compensate for lost function and, where appropriate, recommend to the physician a plan of treatment. However, while the skills of a qualified occupational therapist are required to evaluate the patient's level of function and develop a plan of treatment, the implementation of the plan may also be carried out by a qualified occupational therapy assistant functioning under the general supervision of the qualified occupational therapist. ("General supervision" requires initial direction and periodic inspection of the actual activity; however, the supervisor need not always be physically present or on the premises when the assistant is performing services.) Skilled Nursing Facility Manual. Chapter Direct Skilled Rehabilitation Services to Patients. C. Occupational Therapy.--General. Coverage Criteria.--To constitute covered occupational therapy for Medicare purposes the services furnished to a beneficiary must be (a) prescribed by a physician, (b) performed by a qualified occupational therapist or a qualified occupational therapy assistant under the general supervision of a qualified occupational therapist, and (c) reasonable and necessary for the treatment of the individual's illness or injury. 5-Conclusion The rehabilitation therapy provided to Mx was within acceptable medical standards. FH61 FH03a - Developed - Developed by Polaris by Polaris Group Group Page Page 30 of 41 31of 57

43 The skills of qualified therapists were necessary to provide the services including gait training, balance training, bed mobility training, and self care training. Skilled intervention included teaching Mx proper technique and adding challenges/upgrading goals as the patient improved. Based on evaluation results, the therapist had reasonable expectation of improvement for this patient with skilled intervention. The expectation of improvement was based on the patient s prior level of function, A & O x 3 cognition, and documented progress during the billing period. The frequency and duration were reasonable considering positive prognostic indicators and acceptable medical standards. Significant gains in targeted areas resulted from skilled intervention. The patient improved in gait, bed mobility, balance, self care, and transfers. The patient only experienced these benefits as a result of skilled intervention by qualified physical and occupational therapists. We respectfully submit the above information for review and request overturn of the denial of the services for the claim in question. We believe the services provided were reasonable for the patient and were in compliance with Medicare coverage guidelines. We further believe the evaluation and treatment provided to Mx were medically necessary for the patient s condition and feel strongly that the patient would not have experienced the same functional gains with nursing care in the absence of skilled physical and occupational therapy. Signature including credentials FH61 FH03a - Developed - Developed by Polaris by Polaris Group Group Page Page 31 of 42 31of 57

44 EXHIBIT A HEADING Date: XX/XX/XXXX To: From: Subject: Name including credentials: Facility Name: Provider #: Denial of Medicare services for: HIC#: Dates of Service: Dates Denied/Downcoded: Type of Service: Physical and Occupational Therapy, etc INTRODUCTION The above referenced claim has been selected for an Additional Development Request. Along with the requested documentation, we are including this letter which summarizes the skilled services provided to the beneficiary as required by the Medicare Benefit Policy Manual. For your convenience, the pages of the medical record are numbered and circled in the lower right hand corner of each page. RESIDENT IDENTIFICATION Overview of Hospitalizations and Skilled Nursing Facility Admissions o The 81 year old beneficiary hospitalized for compression fractures after a fall at home. She laid on floor for two days before being found. She has Parkinson s disease. Her physician noted she also had a suggestion of pneumonia upon admission. While hospitalized she had an arteriogram, aortogram and subsequently a right common iliac angioplasty and stent graft. At time of discharge she did have cyanosis present in 2 nd and 3 rd toes of the right foot and it was suspected she also had slough and necrotic tissue on those toes. On 07/03/XX she had confusion and was started on Geodon. She was subsequently diagnosed with a CVA. She had anemia, rhabdomyolysis, aspiration pneumonia, fever and hypoxia. Initial SNF Admission: 06/18/XX to 07/18/XX: Admitted to SNF o She was admitted for aftercare for vertebral compression fractures, personal history of fall, pneumonia, and back pain. She was on PEG tube/enteral feedings. She FH61 - Developed by Polaris Group Page 43 of 57

45 had need for multiple therapies due to her pneumonia, failure to thrive, DVT, osteoporosis, anemia, seizure disorder, and hypertension, history of CVA with right hemiparesis, depression with anxiety, Parkinson s disease, wound care and weakness. 1. ISSUE: I would like to request a reconsideration of the denial of skilled rehabilitation services for the above claim dates. The denial reasons at redetermination (per the decision letter dated XX) were stated as: o There was not a valid order for provision of OT treatment 6 days a week; o Speech therapy services were not initiated in the hospital and no documentation was submitted to support the deficits noted by speech were related to the admitting diagnosis o Documentation was missing hospital records and additional records to support the 06/XX ARD reference dates. These denial reasons will be addressed below, and the documentation provided supports that the skilled nursing and rehabilitation services received by the beneficiary between 6/18/20XX and 7/18/20XX were reasonable, necessary and provided as billed. Therefore, we respectfully request that these services be paid at the original RUG billed. 2. RESPONSE TO DENIAL: We disagree with the denial and respectfully request reconsideration due to the evidence cited below. 3. FACTS OF THE CASE: Beneficiary s condition(s) that require and/or contributed to the need for said services: o The following is a synopsis of care and services provided to the above beneficiary with additional supportive statements and clarification for the billing of therapy services resulting in the rehab RUGs being billed. Services were skilled, plan of care was adjusted daily and was not routine and finally were medically necessary to progress the patient to her highest level of function. The beneficiary was a high risk for re-hospitalization and therapy services were a key factor in preventing this both during and after her stay at XX facility. Due to the beneficiaries prior level of function and the beneficiary s wiliness to participate with therapy the expected outcome was highly likely that the beneficiary would be able to return to their home safely. FH61 - Developed by Polaris Group Page 44 of 57

46 Prior Level of Function: o The beneficiary was living independently in the community. Prior to her hospitalization, the beneficiary was independent with all ADLs and functional mobility. Beneficiary was also able to do laundry, cook, clean, administer medications and drive independently. Treatment plan: o The treatment plan for physical therapy included therapeutic activities, neuromuscular re-education, w/c management, gait training, and therapeutic exercise. For occupational therapy the treatment plan included self-care retraining, neuromuscular reeducation, therapeutic activities, and therapeutic exercise. Facts that indicate a reasonable expectation for significant improvement if services were rendered: o Prognosis for achievement of goals was good due to the patient s prior level of function, recent onset of difficulties, ability to participate in treatment tasks, and good motivation to return to prior functional level. Doctor s authorization for services in controversy: o "Physician's Order Form" dated June 20XX which includes physician orders for skilled physical and occupational therapy to eval and treat. The physician order form was also signed and dated 6/19/XX by the physician. The record also contains multiple physician orders dated from 6/17/XX, through discharge orders dated 7/18/XX. o The initial Physical therapy and occupational therapy plans of treatment were signed by the physician on 6/19/XX beneath the statement I certify the need for these services furnished under the plan of treatment and while under my care. Evaluation Results: o The beneficiary was evaluated by physical therapy and occupational therapy on 6/19/20XX. Beneficiary demonstrated good rehab potential based on her prior level of function. Based on the demonstrated functional decline, a plan of care was established to address the below performance areas, with progress as noted below: FH61 - Developed by Polaris Group Page 45 of 57

47 TRANSFERS: Interventions Provided AMBULATION: Interventions provided Status on (XX/XX/XXXX) Status on (XX/XX/XXXX) Sit to stand from wheelchair to bed Moderate assistance with frequent verbal/tactile cues. Could perform minimal assist to contact guard assist at start of session but fatigued quickly requiring more assistance. Graded Sit to Stands exercise, squats (tilt table with movable platform to perform squats less than body weight for progression) skilled intervention to progress patient into bearing more body weight as strength improved. Rhabdomyolysis causes muscle weakness and pain requiring skilled intervention to progress at an appropriate level. Education and skill practice on proper sit to stand sequencing. MFAC electrical stimulation for bilateral quads to facilitate improved muscle fiber activation. Added floor to chair transfers. (patient laid on floor for 2 days at home from last fall) Needed to be able to get off floor in the future. This is a skilled intervention requiring scaling of the activity and breaking the task into multiple steps this could not be accomplished through a restorative or non-skilled intervention. This patient s plan of care and interventions fit the description per the Medicare Policy Manual, Chapter 8, and Section that states the requirements for skilled PT services feet with front wheeled walker with minimal to contact guard assist but by end of distance had a very flexed posture and required moderate assist due to quick fatigue causing knee buckling due to quadriceps weakness. Gait Speed: slow Gait training on stairs, extensive gait training for gait velocity, gait speed, step length and step through, Recommend athletic shoes with family providing shoes for improved stability with 100% cues needed for floor to chair transfers, stand by assistance for sit to stand transfers needed for safe sequencing using the front wheeled walker. 200 feet with front wheeled walker needing less verbal cues to increase step length and gait speed. Demonstrate alternating gait pattern for ascending stairs and step to gait pattern descending stairs. Selfselected walking speed was.5 m/sec well below required for community ambulation. With cuing for her fast walking, increased to.7 m/sec which is still below the.8m per sec needed for community ambulation. FH61 - Developed by Polaris Group Page 46 of 57

48 ADDITIONAL INTERVENTIONS PROVIDED: Toileting Interventions Provided Status on (XX/XX/XXXX) Status on (XX/XX/XXXX) walking. Vital sign monitoring of blood pressure due to complaints of dizziness upon standing.. Low activity tolerance would make it difficult to effectively manage in her apartment. Strictly a restorative program would not progress distance, address gait deviations such as postural correction. Restorative walking would have just strengthen her poor gait pattern and not changed it to a more effective and efficient gait pattern. CES-D scale (screen for depression) scored 34/60 indicating depressive symptoms team communicated and plan of care developed. Made referrals to psychiatric care services to assist with depression. Recognition of her depression was key to improving the overall function, safety and mobility of this individual. Comments at the end of her stay to her physical therapist was You saved my life. The therapeutic relationship formed with this patient was another factor in her successful recovery. Reviewing therapy notes and seeing the multiple times that he was down and/or crying in therapy, a CNA would have not completed any restorative services instead would have wrote, Patient refused. Again reason that it can be deduced that this patient would not have progressed adequately by only restorative services. Standby Assistance for sit to stand from toilet with one hand rail and one on walker, stand by assistance with bilateral upper body support of walker, dependent for peri-cares. Skill practice in toileting techniques, functional reaching tasks and interventions under dressing. This included skilled observations and suggested changes to make appropriate recommendations for techniques. It also included identifying impairments related to her difficulty with her peri-hygiene resulting in working on her core strength for her ability to lean and change position on the toilet to assist with wiping. Hand grip and pinch strengthening exercises were also provided to improve ability to wipe and manage pants during toileting. OT interventions were constantly changed as patient progressed. The supports the requirement for skilled OT services per the Medicare Policy Manual Chapter 8, NOTE: Updated plan of care on XX/XX/XXXX extending therapy for 5-6 times a week for an additional 6 weeks. Maximal assistance for peri-hygiene, clothing management moderate assistance, contact guard for the transfer. Toileting ability is a major aspect of a person being able to return home safely and incontinence is a factor in falls. FH61 - Developed by Polaris Group Page 47 of 57

49 If denial was based upon whether skilled services were reasonable and necessary specify why were needed: o The beneficiary was referred for evaluation and treatment by occupational therapy, physical therapy after admission to the facility on 6/17/20XX due to noted decline in functional mobility, self-care performance, strength, endurance and balance. o The physician s order was not given sufficient deference by the reviewers. According to the treating physician rule, the treating physician s opinion on the diagnosis, nature and degree of impairment and treatment is: (1) binding on the fact finder unless contradicted by substantial evidence; and (2) entitled to some extra weight, even if contradicted by substantial evidence, because the treating source is inherently more familiar with a beneficiary s medical condition than are other sources (Scherler v Bowen, 851 F2d 43 (2nd Cir. 1998)). (See also, State of New York v Sullivan, 927 F2d 57, (2nd Cir. 1991); Pfalzgraf v Shalala, 997 F Supp 360, (WDNY 1998); Smith o/b/o McDonald v. Shalala, 855 F Supp 658, (D. Vt. 1994) ( the Secretary is expected to place significant reliance on the informed opinion of a treating physician ); Kiernan v. Shalala, 5:91-CV-58 (D. Conn. July 11, 1994) (ALJ s findings that the subject services could have been rendered more effectively in a less intensive setting were reversed because the ALJ was required to give heightened attention to the opinion of the beneficiary s treating physician or to offer a reasoned basis for declining to do so). Physician Certification 6/17/XX -The initial certification for skilled services was signed by the physician certifying that post-hospital skilled nursing facility services are required to be given on an in-patient basis because of the beneficiary s need for skilled nursing and/or skilled rehabilitation on an inpatient basis. 6/17/XX 1 st recertification signed by the physician certifying that continued inpatient care is necessary for 30 more days as follows: PT and OT for gait and strengthening. Skilled nursing for PEG tube nutrition support, wound care, aspiration pneumonia and failure to thrive.. Discharge goal is to return home or assisted living facility. 4. RULE: See above grid for additional rules Federal regulations provide that [e]ach resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psycho social well-being, in accordance with the comprehensive assessment and plan of care (42 C.F.R ). The regulations further mandate that a facility ensure that a resident s abilities in ADLs do not diminish unless her/her clinical condition makes deterioration unavoidable (Id). As part of the surveyor s review of a facility, CMS specifies that if, over time, a resident has no change in her or her ADL capabilities, or experiences a decline in her ADLs, the surveyor must scrutinize the FH61 - Developed by Polaris Group Page 48 of 57

50 facility s actions to determine whether an intervention would have been appropriate (42 C.F.R (a) and Commentary to State Operations Manual, CMS Pub. 7, Appendix P, F310). Consequently, where, as here, there is a change in the beneficiary s overall condition, which clearly impacted independence and safety with ADL and functional mobility, the physician, consistent with CMS direction, ordered the needed therapy. 5. CONCLUSION: This was a complicated patient compounded by lack of medical attention for many years and poor social support. Due to her rapid decline in her functional status due to her fall with subsequent prolonged immobilization on floor, patient became very dependent with wounds, extreme weakness and depression. Pain management was an issue throughout her stay due to her wounds, soft tissue injuries, etc. A decline in the beneficiary s level of independence and safety from her prior level of function was clearly established with the therapy evaluations. Skilled rehabilitation services were provided with the goal to return to a prior level of independence for safe discharge back to the community. The Therapy Service Log records provided verify the minutes documented for the MDS were accurate and reflect the services provided by therapy. The beneficiary made significant functional gains with all therapy during the dates of service under review, and services were continued with an expectation of the beneficiary s returning to an Assisted Living Facility independently after rehabilitation stay. In conclusion, as the information provided above indicates, the services rendered were medically necessary and the condition of the beneficiary required the judgment, knowledge and skills of a qualified therapist. It is our opinion nursing and therapy provided all care in accordance with Medicare and OBRA guidelines and reflected the philosophies stated in the Medicare Benefit Policy Manual, Chapter 8, Section 30 Skilled Rehab Services and Chapter 15, Section 220. Thank you for your reconsideration in the denial of services for the beneficiary. We feel very strongly that the beneficiary required skilled nursing and rehabilitation services to enable the highest level of independence for improved quality of life. Sincerely, Signature Including Credentials Facility Name FH61 - Developed by Polaris Group Page 49 of 57