Additional Documentation Requests & Denial Trends

Hello from the Synergy Care Denials & Appeals Department! We want to take a moment to update you on the latest trends related to ADR’s (Additional Documentation Requests) and Denials. There are many different types of ADR’s. Some frequent ADR types we see are:

RAC (Recovery Audit Contractor Reviews) audits of traditional Medicare claims
TPE (Targeted Probe & Educate Audits) pre or post pay reviews of traditional Medicare claims focused on a particular targeted area
PDPM audits from managed care companies

After the documentation for an ADR is reviewed, a decision is rendered. A favorable outcome with no findings is the desired outcome. However, some claims are denied after audit review. Here are a few of the prevalent denial types we have recently appealed. RAC/TPE Audit Denials

Physician Certification and/or recertification denials
- Missing signatures
- Physician’s signature was not dated or out of date range
- Estimated time of remaining skilled care was not included
Documentation does not support medical necessity or targeted area reviewed

PDPM Audit Denials

Diagnoses not supported as active (Malnutrition, DM, COPD, Obesity)
IV fluids for hydration while not a resident
Isolation
Mechanical soft diet, CVA (SLP component denials)
Section GG support

So, what are some strategies to ensure your success in the ADR/Denials process?
-Use a checklist to ensure all documentation is submitted to support billed services

-Ensure Physician’s Certification/Recertification is completed timely and in its entirety, and is included in documentation submitted for RAC audits

-When coding the MDS, be make sure to look for the two lookback periods to support Active Diagnoses:

Diagnosis identification: (Step 1) is a 60-day look-back period.
Diagnosis status: Active or Inactive (Step 2) is a 7-day look-back period.

-Educate on importance of daily skilled narrative documentation. Daily skilled nurse’s notes indicate skilled intervention which may consist of observing, assessing, educating, training, and managing the overall care of the beneficiary.

-Thorough documentation by the entire Interdisciplinary Team to demonstrate collaborative care to support HIPPS codes billed.

We strive to stay up to date on the latest trends and changes related to ADR’s & Denials. Please reach out to your Synergy Care contact with any questions you may have. We are here to assist you!

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We are devoted in our commitment to providing education and updates to you as they become available. Thank you for your hard work and commitment through these ever-changing times.