Harmony Healthcare I N T E R N AT I O N A L... A COMPLETE GUIDE TO... Successfully Avoiding Denied Claims During these times of reduced census, it is important Harmony Healthcare to keep a clear focus on insulating revenue through I N T E R N AT I O N A L detailed and thorough clinical documentation.
Avoiding Denied Claims During these times of reduced census, it is important to keep a clear focus on insulating revenue through detailed and thorough clinical documentation. Recently, the Office of Inspector General (OIG) published a report describing significant Medicare payment denials based on a post-payment audit. The details of this audit [found at this site] clearly reinforced the need for a heightened sense of attention, dedicated to the documentation of skilled care, that can only be achieved through a targeted path of continuing education and rigorous oversight. It s no longer uncommon for facilities to receive communications from Medicare review agencies requesting proof of skilled services. To further complicate matters, it isn t outside the realm of possibility that facilities could be scrutinized by multiple review agencies, rather than just one. There are Zone Program Integrity Contractor (ZPIC), Recovery Audit Contractor (RAC), and Comprehensive Error Rate Testing (CERT) audits to name just a few. Facilities that are lucky will receive notice to have only one record reviewed, whereas others may have requests involving upwards of dozens of claims. As much as we d like to simply stop auditors from knocking on our doors, that probably isn t a viable solution. Strong facility processes, ongoing education, and frequent medical record spot checks are the most effective ways for every facility to ensure that the medical records can stand up to review. An intimate knowledge of the ever changing Medicare regulations is also a must because out-of-date documentation forms can ultimately result in technical denials. To see how well your medical record will hold up under review, take the Harmony Healthcare International (HHI) Denied Claims Appeals Process Proficiency Exam. We encourage you to follow-up with your team members on these topics, and as always, Harmony (HHI) Consultants are standing by to answer any questions you may have. We ve also included a Denied Claims Appeal Help Letter Review Checklist and some additional tips to take with you after you ve made it through the test. Good luck! 1
Denied Claims Appeals Process Proficiency Exam: Let s Play 20 Questions! 1. To what degree does your facility have a monthly Triple Check system in place? a. The team meets every month to review UB-04s, MDS assessments, and Therapy Billing Logs b. The team tries to meet each month, but sometimes it s hard to get the team together c. The Billing Department double checks everything d. There is no a Triple Check system in place 2. Which key members of your staff should participate in a Triple Check Meeting? a. Representatives from the Billing, MDS, and Therapy Departments b. Representatives from Billing and MDS Departments c. The Billing Department d. Nursing Supervisors 3. ICD-9 codes on the UB-04 are determined using which of the following methods? a. The ICD-9 coding is updated monthly as the patient s skilled nursing and therapy needs change b. The ICD-9 coding is determined shortly after the patient is admitted based on nursing and therapy needs c. The ICD-9 coding is discussed by the team prior to end of month billing to ensure codes reflect the reason for hospitalization and skilled nursing needs d. ICD-9 codes on the UB-04 are not a priority and likely do not reflect the patient s skilled needs 4. The process for sequencing of ICD-9 codes on the UB-04 is as follows: a. ICD-9 code sequencing is prioritized by the most pertinent skilled care needs of the patient, including the use of V-Codes b. ICD-9 codes are prioritized by the most pertinent skilled care needs of the patient, excluding V-Codes c. The ICD-9 codes are ordered based on the hospital discharge summary d. ICD-9 codes are not sequenced. 5. Which of the following best describes your facility process for correlating ICD-9 codes on the UB-04 to the ICD-9 codes on the MDS and therapy evaluations? a. ICD-9 codes are discussed and confirmed as an interdisciplinary team, ensuring that all diagnoses are documented in the medical record, and then codes from the MDS and therapy evaluations are communicated to the Billing Department b. The MDSC pulls ICD-9 codes off of therapy evaluations and includes them on the MDS, the Billing Department pulls ICD-9 codes off the MDS and includes them on the UB-04 c. The UB-04 and MDS ICD-9 codes correlate, but therapy ICD-9 codes are not included d. There is no system in place to ensure ICD-9 codes on the UB-04 correlate to the MDS and/or therapy evaluations 6. Which of the following best describes how therapy ICD-9 codes are supported on the therapy evaluations? a. ICD-9 codes are carefully selected to best reflect what makes up more than 50% of the patient s functional limitation b. ICD-9 codes are chosen off a short list in the therapy department based on the patient s functional limitations c. The same ICD-9 codes are used on almost all patients d. Therapy does not select ICD-9 codes 2
Denied Claims Appeals Process Proficiency Exam:...continued 7. Which of the following best describes how the therapy professionals maintain compliance with the frequency prescribed in the therapy orders? a. Therapists order the frequency of visits in a range (i.e. 5 7x/week) and diligently adhere to them b. Therapists have a set number of days (i.e. 5 x/week) and carefully track visits to ensure compliance with the Medicare Treatment Week c. Therapists have a set number of days (i.e. 5x/week) and provide treatments based on a Calendar Week d. Therapists do not track the frequency of visits for accuracy 8. Which of the following best describes how timely physician signatures are obtained on therapy evaluations? a. A system is in place to ensure timely signatures by the physicians, either in person or faxed, and therapists follow-up on their evaluation forms to ensure this has been done b. A system has been put in place to make an effort to obtain timely signatures by the physician, but sometimes there is poor follow-through c. Therapy evaluations sit in a folder either on the unit or in the therapy gym; physician signatures are not always obtained timely d. It is very difficult to obtain a timely signature on a therapy evaluation 9. Which item best represents how therapy evaluations support a decline in function? a. Therapy evaluations document a clear prior level of function and a significant decline from the patient s highest practicable level of function b. Therapy evaluations document a clear prior level of function, but not all functional areas are tested on evaluation c. Therapists are not always able to obtain a prior level of function or not all functional areas are tested on evaluation d. Evaluations lack the details required to support a decline in function 10. How do the therapy progress notes support ongoing skilled services? a. Weekly progress notes clearly document gains from one level of assist to another, gains within each level of assist, the skilled interventions provided to the patient over the past week, and/or the plan to elicit gains in the upcoming week b. Progress notes document gains from one level of assist to another and skilled interventions; notes lack details needed when gains are slow and there is minimal documentation of the next week s plan c. Progress notes document the current level of function, but do not compare it to the previous week, document skilled interventions, or the upcoming week s plan d. Progress notes are vague, without measurable data demonstrating gains 11. How do daily therapy notes support skilled interventions? a. Daily treatment notes document the skilled interventions provided to the patient and document the clinical judgment of the therapist, including the rationale behind group treatments and co-treatments b. Daily treatment notes list the therapeutic exercises done and the levels of assist required to complete ADL and mobility tasks; the rationale behind group and co-treatments is also included c. Daily treatment notes list CPT codes billed; specifics of the treatment sessions are sparse, justification for group and/or co-treatment is not included d. The therapists do not complete daily treatment notes 3
Denied Claims Appeals Process Proficiency Exam:...continued 12. Which of the following best describes the steps taken for obtaining timely signatures on MDS interviews? a. MDS interviews are conducted on or before the ARD, when indicated, and staff sign Section Z0400 on the date the interview was completed; as well as signing other non-interview components of Section C and J after the ARD b. MDS interviews are conducted on or before the ARD, when indicated, and staff sign off on the entirety of Sections C, D, F, and J in Section Z0400 on the date the interview was completed c. MDS interviews are conducted on or before the ARD, when indicated; staff sign Section Z0400 after the ARD d. Efforts are made to conduct MDS interviews on or before the ARD, when indicated; The MDS Coordinator tells staff members what date to put in Section Z0400 13. Who ensures that all items coded on the MDS are supported in the medical record? a. When coding the MDS, MDS Coordinators do a thorough review of the medical record and interview staff members to obtain an accurate picture of the patient; any information gathered through interview that is not documented in the medical record is supported through an MDS Note b. When coding the MDS, MDS Coordinators do a thorough review of the medical record and interview CNAs/ Licensed Nurses for ADL information; ADL information obtained through interview is not supported through an MDS Note c. When coding the MDS, MDS Coordinators do a thorough review of the medical record as well as code information based on their perceptions/observations of the patient; information documented from staff perceptions is not supported through an MDS Note d. The MDS is coded based on MDS Coordinators perceptions/observations of the patient and partial medical record review 14. Are Physician Certification Forms utilized and signed compliantly? a. Physician Certification Forms are in use; a system is in place to ensure timely signatures by the physicians, either in person or faxed b. Physician Certification Forms are in use; a system has been put in place to make an effort to obtain timely signatures by the physician, but sometimes there is poor follow-through c. Physician Certification Forms are in use, but sit in a folder either on the unit or in the MDS Coordinators office; physician signatures are rarely obtained timely d. Physician Certification Forms are not in use 15. Accuracy on the Physician Certification Forms to reflect the skilled care provided by the Nursing and Therapy departments is achieved through which process below? a. Skilled qualifiers notated on the Certification forms are discussed as an interdisciplinary team and reflect the details of both nursing and therapy skilled services b. Skilled qualifiers are pulled from the hospital discharge summary; therapy disciplines are also listed if the patient is evaluated per physician orders c. Physician ordered therapies are listed on the form; the skilled nursing needs are only included if therapy is not involved d. Physician Certification Forms are not in use 4
Denied Claims Appeals Process Proficiency Exam:...continued 16. How are the nursing notes entered in the medical record each day that the patient is using his or her Medicare Part A benefit? a. There is a narrative skilled nursing note from each shift daily that the patient is utilizing his or her Medicare Part A benefit with details of the Licensed Nursing staff s clinical reasoning skills and observations/assessments b. There is a narrative skilled nursing note every day that supports the patient s primary skilled diagnosis c. The daily skilled note is in the form of a skilled check-list; the narrative component of the note is sparse or absent d. The nursing staff struggles to complete a note every day of the patient s Medicare Part A stay 17. To what degree do daily skilled nursing notes reflect that the skills of a licensed nurse were required on a daily basis and relate to a condition that required hospitalization or a condition that arose as a result of the skilled nursing home stay? a. Daily skilled nursing notes clearly state the diagnoses for which the patient is being skilled, as well as pertinent observations/assessment and teaching/training; the notes create a story and flow from the previous note b. Daily skilled nursing notes clearly state the diagnoses for which the patient is being skilled, but the details of the note do not consistently reflect the skills of a Licensed Nurse c. Daily skilled nursing notes document vitals, intake, pain management, and the patient s respiratory status; additional details are not always present d. The nursing staff struggles to complete a detailed skilled note every day of the patient s Medicare Part A stay 18. How is coding of Respiratory Therapy supported in the medical record? a. Respiratory Therapy relates to the patient s diagnosis, is supported with a physician s order, and is documented on a flowsheet/mar/tar demonstrating at least 15 minutes per day, seven days a week; additional respiratory observations and assessments can be found in the daily skilled nursing notes b. Respiratory Therapy is supported with a physician s order, and is documented on a flowsheet/mar/tar demonstrating at least 15 minutes per day, seven days a week; additional respiratory observations and assessments can be found in the daily skilled nursing notes; all patients respiratory statuses are monitored regardless of diagnosis c. Respiratory Therapy is coded on the MDS, but documentation of the minutes provided to the patient are not documented in the medical record d. Respiratory Therapy is never coded on the MDS 19. How well does the ADL documentation in your facility support the coding on the MDS? a. ADL flowsheets are in place, along with correction sheets, and are competed by each shift daily; daily skilled nursing notes also contain ADL information; the MDS Coordinator interviews front-line staff to gain a deeper understanding of the assist provided and documents findings in an MDS Note b. ADL flowsheets are in place and completed on most shifts, most days; the MDS Coordinator also interviews frontline staff to gain a deeper understanding of the assist provided, but does not document findings in the medical record c. ADL flowsheets are not in place, but ADL information can be obtained through nursing and therapy notes; the MDS Coordinator interviews front-line staff, but does not document findings in the medical record d. ADL coding on the MDS cannot be verified in the medical record 5
Denied Claims Appeals Process Proficiency Exam:...continued 20. Which system is in place to ensure closed records are complete? a. Closed records are reviewed by the interdisciplinary team with a Closed Record Checklist to ensure all documents are present, signed, and demonstrate the clinical needs of the patient b. Closed records are reviewed by MDS and/or a Nurse Director with a Closed Record Checklist to ensure all documents are present and signed c. Closed records are reviewed by Medical Records with a Closed Record Checklist to ensure all documents are present d. Closed records are not reviewed before storage... Your Score Mostly a : You are the cream of the crop! Keep the momentum rolling by ensuring that your staff receives ongoing education of changes to the Medicare system, regular chart audits to ensure consistency in the documentation, and quarterly in-services to keep staff members fresh and excited.... Mostly b : Well done! Now it s time to focus on the tough stuff. Fine tune the systems that are in place to ensure consistency and good communication, elevate the therapy and nursing documentation to the next level, and ensure that all your recourses are being captured.... Mostly c : You re doing a good job with the basics, but there is an opportunity to improve the Interdisciplinary processes within the facility, as well as the details of the documentation. Your facility may be leaving itself open to audits. It s even possible that your facility has been audited and denied claims. It s not too late to protect yourself!... Mostly d : We know how difficult this process is and there seems to be a number of opportunities for you to improve on. Staff members are struggling to understand Medicare guidelines and are likely not finding the resources they need. Communication within and between departments is challenging. RUG scores are not reflective of the good care being provided, and revenue is poorly insulated. There is help out there to move those d answers up to a answers!
Denied Claims Appeal Help Letter Review Checklist Period Skilled Nursing Chart Review: From: To: Medicare Admission Date: Diagnosis: MDS Reference Dates Review...... ARD Billing Dates 5 Day 14 Day 30 Day 60 Day 90 Day SOT/EOT OMRA RUG/HIPPS COT COT COT COT COT COT ARD Billing Dates RUG/HIPPS ICD-9 Codes MDS Forms Completed Since Admission (MAC may only request for billed period) q MDSs that cover days billed q ARDs set in acceptable time frames q Signed by all disciplines q Interviews are signed on day interview completed q Signed by RN Coordinator q Documentation to support Rehab RUG in Section O q Documentation to support coding IVs in Section K & O (from hospital if applicable) q Documentation to support ADL coding in Section G q RUG rate matches billed rate on UB-04 q Z0500B within 14 days of ARD q OMRAs completed when necessary and within appropriate time frames q Interviews completed, not dash-filled q Documentation present to support diagnoses coded in Section I q Documentation present to support Shortness of Breath in Section J 7
Denied Claims Appeal Help Letter Review Checklist...continued Physician Certification q Signed on admit q Recertification signed by day 14 and every 30 days after for entire billing period q Details regarding skilled nursing services present q Details regarding skilled therapy services present Physician Orders for Review Period q Monthly orders signed by physician q Interim orders signed by physician q Telephone orders signed by physician q Number of days of order changes match MDS q Therapy evaluation orders present and signed q Therapy clarification orders present and signed q Therapy recertifications present and signed History and Physical q Hospital and Facility H&P q RN Pre-admission and screening documentation Physician Progress Notes q Admission note q Physician visits match MDS Acute Care Discharge Summary q Documentation (d/c summary, MAR, Notes) to support look back on MDS (IVs Medication, IV Hydration, Transfusion, trach, vent, surgical wounds, ADLs) while a resident and while not a resident. q Three day qualifying stay verified Nursing Notes q Daily skilled nursing notes present for entire period under review q Daily skilled nursing notes present for MDS look-back periods q Daily notes 30 days prior to ARD date of any MDS billed (Cahaba) q Documentation to support daily skills in Certification q Weekly Medicare meeting summary q Documentation provide to support staff coding of PHQ-9 8
Denied Claims Appeal Help Letter Review Checklist...continued Medication Records q MARs present for MDS look-back periods Treatment Records q TARs present for MDS look-back periods q Minutes on Respiratory Therapy and or nursing treatment sheets match each MDS in billing period q Wound flowsheets completed in full and present for each MDS in billing period Parenteral or Enteral Intake Records to Support Amount Received q Dietician notes for G/J Tube q Treatment or Medication Records q Input and Output if applicable ADL Flowsheets q All dates have been filled in q All signatures present q Corrections included Therapy - For Review Period and 7 days prior to ARD of any MDS billed. q Evaluation signed timely by physician (always include initial evaluation with all review periods) for each discipline provided in ARD and Review period q Updated Monthly Progress Note for each discipline provided in ARD and Review period q Weekly Progress Notes present and support ongoing skilled services q Billing logs for entire period in review q Billing logs for ARD look-back periods q Minutes and days on therapy logs match Section O q Daily documentation supports minutes on billing logs q Daily Notes for each discipline provided in ARD and Review period q Any additional documentation to support functional progress Restorative Nursing Documentation q Plan of care q Daily log q Progress notes at least every 30 days q Physician orders 9
Denied Claims Appeal Help Letter Review Checklist...continued Diagnostic Reports (labs, x-ray) q Include for review period Trach and Vent Documentation q Documentation to support trach care Other documents to support skilled level of care (review billed RUG and include only if needed to support skill/rug billed). q BEHAVIOR: Behavior sheets, Social Service Notes and Psych Documentation q Reduce Physical Functioning: Dietary, possibly detailed care plan to support aggregate of services q Nursing teaching sheets to family and patient q Consult reports Denial Notification if remained in facility and Medicare discontinued at end of review period q Signed by patient or guardian q Check to have Medicare review or decline review Signature Log q Signature Log included for all staff members The following items must be added to this record prior to submitting: 1. 5. 2. 6. 3. 7. 4. 8. Comments/Risk Areas: DON: MDSC: Rehab: Regional/Consultant: 10
6 Quick Tips Medical Reviews: The health care industry is currently experiencing a significant increase in the number of medical review requests from Medicare Administrative Contractors (MACs) around the country. Harmony Healthcare International is researching any existing patterns in the review process to provide our clients with information on how to prepare for a denial free medical review process. Determination decisions are based on the content of the medical record. It is imperative that your staff understands how documentation supports daily skilled care by both nursing and therapies. As well, the record must reflect each service coded on the MDS and billed on the UB-04. Harmony Healthcare International recommends the following steps when filing an appeal of a denied claim with the Medicare Administrative Contractor (MAC): 1. 2. 3. 4. 5. 6. Highlight specific content on each document which supports skilled care provided. For example: MD notation that a patient is making progress and should continue with therapies, social service note which summarized skilled stay and successful discharge to targeted environment.... Review the entire record for documentation from all disciplines that supports skilled care for the period being denied.... Include documentation from the 7-day (or 14 if applicable) look back period. This information is the basis for why the team continued to provide skilled care.... Write a formal narrative letter and submit with all appeals explaining why skilled care was reasonable and necessary during the denied dates of service.... The best way to avoid nursing denials is proactive daily documentation of skilled services provided.... Therapy denials are avoidable with daily notations of each modality provided with weekly narrative notes summarizing skilled intervention. Documentation that states the therapist s expectation that the patient will continue to succeed toward set goals areas / revised goal areas. 11
How We Help Our Clients At this time, facilities cannot afford to be remiss on charting of care provided to patients accessing Medicare benefits. As a result of the increasing medical review of SNF Medicare Part A and Part B compliance, we have heightened our focus during site visit audits on skilled documentation, MD certifications and skilled care criteria of each Medicare beneficiary. Frequent training and reminders to staff regarding the accountability for written reports on each patient can prevent take backs from CMS and insulate the revenue your facility generates. Harmony Healthcare International (HHI) has extensive experience assisting facilities that choose to bring their cases before a court of law, which can be a very daunting process for facilities. Our experts can guide your team through the process to ensure staff members are prepared and confident during all levels of the appeal, including the Administrative Law Judge hearing. Our leadership and expertise can save your staff the time-consuming process of preparing medical records and writing letters, which can devour hours or even days of valuable resources when multiple records are requested, and simultaneously increase the likelihood of the claims being paid. As the appeal process can take upwards of two years if every level of appeal is pursued, knowledge and experience in the appeal process can positively impact accounts receivables.... To learn more about how we can help assist you with your Denied Claims Appeals Process, please contact: Carrie Mullin Director of Denials Management Harmony Healthcare International cmullin@harmony-healthcare.com 978-887-8919 or visit www.harmony-healthcare.com for more information!... Our Mission: Harmony Healthcare International is a professional services organization focused exclusively on assisting skilled nursing facilities to improve patient care. Through in depth, on site, medical record reviews, customized certification & training programs and specialized support for the appellate process, we provide our clients with the specialists to improve patient care while simultaneously insulating their revenue via clinically appropriate Medicare reimbursements. Harmony Healthcare INTERNATIONAL 430 Boston Street, Suite 104, Topsfield, MA 01983 Tel: 978-887-8919 Fax: 978-887-3738 www.harmony-healthcare.com