An Additional Development Request (ADR), also known as an Additional Document Request, is issued for the purpose of reviewing documentation for specific issues as determined by the Centers for Medicare and Medicaid Services (CMS) or other governing agencies of the federal government.
ADRs emanate in part from False Claims Act (FCA) legislation, which originally dates back to 1863 (yes, 1863!). During the Civil War, the FCA (originally called the “Lincoln Law”) was enacted to combat the illegal practice of contractors and suppliers inflating prices to the government for their services. The FCA was not revised until 1986 when new legislation regarding the imposition of fines (termed Civil Monetary Penalties, or CMP for short) and whistleblower protection was added. Another revision in 2009 added the prohibiting of knowingly making a false claim. The most recent revision in 2010 was implemented with the Patient Protection and Affordable Care Act (ACA) – otherwise referred to as the “ACCOUNTABLE Care Act” – which added specific language regarding recovery of overpayments and the timelines for provider return of monies and/or imposition of CMP.
The diagram below illustrates this evolution.
Beginning in 1998, the Office of the Inspector General (OIG) was tasked with engaging the private health care community to prevent submission of erroneous claims and combat Medicare fraud through voluntary compliance. As part of its mandate, the OIG produces compliance program guides (CPGs) for each segment and conducts audits on compliance to those guidelines. During 2016, one of the focal points of the OIG was high therapy utilization for patients in skilled.
With the 2003 Medicare Prescription Drug Improvement and Modernization Act (MMA), the Recovery Audit Program (RAC) demonstration project first began in three states, and then was formally established and expanded to all states in 2009 for full implementation in 2010. The RAC has a three-year look-back, however; if fraudulent practices are found (or suspected), the RAC may refer the issue to the Zone Program Integrity Contractor (ZPIC)—renamed recently to Universal Program Integrity Contractor (UPIC). The ZPIC/UPIC has a 10-year look-back and unlike other auditors, officials may show up at the facility for their audit. If the ZPIC/UPIC is at a facility doorstep, you can be sure that they have reason to believe that the provider is guilty of fraud.
In order to establish and maintain a proactive approach to potential audits, it is vital that your understands and follows the Medicare guidelines for eligibility, service requirements and documentation. The most basic technical requirements, such as the medically necessary three-day hospital stay, must have occurred, and the beneficiary must admit to the facility or have received skilled care within 30 days of hospital discharge. This “three-day stay” must include three consecutive midnights as an inpatient in an acute care hospital setting. Be aware of observation days when reviewing the hospital transfer forms; observation days do not meet the qualifying hospital stay requirement and will automatically invalidate the skilled nursing provider claim.
Medicare skilled service requirements maintain that the beneficiary must require skilled services on a daily basis. In order to meet that requirement, one of the following must be met:
Rehabilitation – PT/OT/ST at least five days per week
Skilled Nursing – seven days per week
Restorative Nursing – at least six days per week
Documentation of skilled nursing and therapy services is required for Medicare reimbursement—and because of increased scrutiny, it is now more important than ever. According to Federal Regulation F 514, the facility must maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete, accurately documented, readily accessible, and systematically organized in order to obtain and maintain Medicare certification.
The Medicare Program includes five broad categories of skilled care:
Observation and assessment – Observation and assessment constitute skilled services when the skill of a technical or professional person is required to identify and evaluate the patient’s need for modification of treatment—or for additional medical procedures until his or her condition is stabilized.
Management and evaluation – The development, management and evaluation of a patient care plan based on the physician’s orders constitute skilled services when, because of the patient’s physical or mental condition, those activities require the involvement of technical or professional personnel in order to meet the patient’s needs, promote recovery and ensure medical safety.
Teaching and training – Patient education services are skilled services if the use of technical or professional personnel is necessary to teach a patient self‐maintenance. There are a number of items that qualify in this category. Some examples of skilled teaching activities include: self‐administration of injectable medications, self‐administration of nebs/inhalers, and care of a recent colostomy/ ileostomy.
Direct skilled nursing services- This may include central or peripheral intravenous therapy, pressure ulcer management, tube feeding (meeting requirements), nasopharyngeal and tracheostomy suctioning, wound management, respiratory therapy treatments, nursing rehabilitation.
Direct skilled rehabilitation service – Examples of skilled rehabilitation can include:
Physical therapy for gait/transfer training, strength training, range of motion, etc.
Speech/language pathology for use of communication aids, swallowing techniques, etc.
Occupational therapy for ADL self-care, splint/brace adjustment/training, etc.
Skilled nursing documentation is required a minimum of every 24 hours. Best practice is to complete twice-daily charting. Twice-daily charting will better assure that the Medicare requirements are met, and it will result in more robust documentation of services—and as a result, better preparation for potential audits.
LTPAC providers should include self-auditing to their Standard Operating Procedures (SOPs). This should include a triple-check process each month prior to finalizing billing, as well as a post-submission audit in which 10 percent (the minimum recommended) of claim volume is audited each month using the charge-to-chart approach.
The Triple Check process is the process in which the facility checks all of the information on the UB-04 for accuracy prior to billing. This includes, but is not limited to, the verification of the following items:
Resident demographic information
Physician orders for skilled services (e.g., IV, PT, OT, ST)
Physician certification and recertification
Nursing documentation to support medical necessity and validating the Minimum Data Set (MDS) assessments:
Hospital stay dates
Medicare as Secondary Payer (MSP) questionnaire completed upon admission
Diagnosis for skilled service – ICD-10 numbers corresponding to diagnosis
MDS Assessment Reference Date (ARD) matches the UB-04 service dates
MDS Section G is supported in the clinical record
MDS Section O: Therapy minutes match therapyservice logs
After the Triple Check is completed and the facility has a “clean claim,” the UB-04 can then be submitted to the payers.
Fully understanding and complying with Medicare guidelines is not only best practice, but also proactive when it comes to ADRs and audits.
Learn more about how to prepare for ADRs before they happen
Following some simple steps at the time that the patient/resident is picked up on therapy caseload can make your ADR process a straightforward one.