Are you one of the many LTPAC providers being bombarded by Additional Development Requests (ADRs) and subsequent denials? Then you know how overwhelming the process can feel. Wouldn’t it be great if you need not worry when those ADRs come in the mail? 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.

Follow These Steps to Streamline Your Additional Development Requests (ADRs)

1. Be proactive - first ensure that there is supporting documentation in the resident chart or EHR for a minimum of 3 days prior to therapy adding the resident to caseload. Documentation should include direct staff observations of a decline or improvement. This will be the basis for reason that therapy will pick up the resident.
2. When the resident has been added to caseload, the therapist will have medical and therapy diagnosis codes on the evaluation. These diagnoses must then be supported in the medical record. It is therefore imperative that the diagnoses are added to the resident chart. It is important is that the diagnoses match throughout the resident chart. This means that the diagnosis codes should be identical in the resident diagnosis section of the chart, in the therapy section of the chart, and on the UB-04.
3. Another key component to successful ADR response is ensuring that you have signed orders for therapy. Often times we will see that a resident has an order for “PT/OT/ST eval and treat”. This order on its own will not be sufficient. If a therapy discipline wants to continue to treat a resident they need to write an order for the related discipline and specific reason that they need therapy, such as gait imbalance. The order must also include the anticipated frequency and duration of the therapy (not to exceed the certification period).
4. The documentation in the nurses’ notes should continue at a minimum daily for the entire duration of the therapy treatment. This documentation will further substantiate the need for continued therapy and the residents’ progress.
5. Certification and subsequent recertification is also required as part of your documentation process. If your Certs/Recerts are incomplete, incorrect or untimely then the ADR will most certainly be denied. We frequently see incomplete certs that do not contain the specific therapy information required. When completing the cert/recert for therapy services make sure to include the specific therapy discipline, the condition being treated, the treatment diagnosis as well as the supporting medical diagnosis. Another common mistake is that the physician signs the cert form and the MDS nurse will date it. The regulation is very clear. The physician must sign and date all certs and recerts.
6. Use critical thinking and look closely at the therapy to determine if it is “reasonable and necessary” for this resident. (Think like an auditor – objectively). Each resident should be evaluated on an individual basis. Make sure you are familiar with and are following the guidelines set forth by the Centers for Medicare & Medicaid Services (CMS) and your local Medicare Administrative Contractor (MAC). Both CMS and the MACs issue Coverage Determinations (either National or Local) that detail the documentation requirements for documentation of services. Critical thinking is also vital when determining the frequency and duration of the therapy needed. Ask yourself “Is there a continued need for skilled services?“ When determining the need for continued therapy, you must always take into account the complete resident picture. If it seems unreasonable to you, then it will to an auditor.
7. Ensure that the resident care plan addresses the condition for which therapy is treating. The therapy plan of care is not sufficient on its own. You will need to update the nursing care plan to reflect the current need for therapy treatment. The nursing care plan should include decline/ improvement in Activities of Daily Living (ADLs), increased/decreased need for staff assistance, associated diagnoses and any other resident specific information related to their need for therapy.
8. The final and most important step is to hold your department managers accountable for their assigned portions of this process. You need to work together in order to have desired positive outcomes. Include the reason for ADRs and the outcomes in your QA process to be sure you are addressing staff educational needs.

Making the above steps part of your facility routine will ultimately change the dreaded ADR process into “no big deal”.

Need help with your processes so you’re ready for ADRs before they happen? Contact Richter Healthcare Consultants to request a free consultation.