Nearly every provider has been the recipient of the dreaded Additional Development Request (ADR) letter from a Medicare contractor or managed care organization. ADRs are becoming more and more frequent, so it’s imperative to become savvier in the ways in which you manage them.
Our first recommendation is that you have in place a way to track the ADRs you receive. The tracking form should include the following items:
The resident identification number
Medicare number or HIC, bill type
Statement to and from dates
Claim total
Expected reimbursement
ADR received date
ADR due date
Date that the medical records were mailed
Claim status location (in the Medicare online system)
Decision date
Medical review decision
Payment amount
Balance due
Redetermination/appeal date
Appeal decision and comments
For a downloadable version of an example of an ADR tracking log, click here.
Compiling all of the necessary documentation for an ADR can be a daunting task. Below is a list of guidelines to help you ensure you have everything you need. A good rule of thumb is to only include what is being asked for; do not include information outside of the service dates requested. Also, make sure that the resident’s full name is on every page, and that it is legible.
Hospital documentation to include:
Hospital discharge summary
Hospital transfer forms
Administration records to include:
Medication administration records (MAR)
Treatment administration records (TAR)
Respiratory administration records (e.g., vent, trach, nebulizer, oxygen)
Documentation to support each of the HIPPS codes billed including notes related to each Assessment Reference Date (ARD):
Ensure that every page has the resident name and date clearly visible
Minimum Data Set (MDS) documentation to include:
A printed copy of each MDS related to the billing period being requested
Documentation to support each of the look back periods requested, and documentation to support each of the look back periods which may fall outside of the billing period (the lookback or observation period is the 7, 14, 30 day prior to and ending on the ARD)
Physician documentation to include:
Physician certifications and re-certifications for skilled care including physician signature and date. Re-certifications must include the need for continued skilled care for the time period requested
Physician orders for the time period requested
Physician admission orders for the time period requested
Physician progress notes for the time period requested
Physician history and physical for the time period requested
Nursing documentation to include:
Nursing notes for the time period requested
Nursing assistant documentation for the time period requested (ensure you have included any documentation for the look back period from MDS)
Admission assessment for the time period requested
Nursing assessments for the time period requested (e.g., Braedon, Falls, Aims, Bowel & Bladder)
Resident care plans for the time period requested
Resident vital signs for the time period requested
Skin care / wound care treatment sheets for the time period requested
Therapy documentation to include:
Initial therapy evaluation for the time period requested
Therapy re-evaluations for the time period requested
Objective and measurable prior level of function and current level of function to support functional decline
Therapy plan of care for the time period requested
Therapy progress notes for the time period requested
Therapy treatment records / grids / logs for the time period requested
Any other documentation supporting the beneficiaries’ need and delivery of the skilled care services being provided in the SNF
Social service documentation
Social service assessment/s for the time period requested
Social service progress notes for the time period requested
Resident care plans for the time period requested
Dietary documentation
Dietary assessment/s for the time period requested
Resident care plans for the time period requested
Dietary progress notes for the time period requested
Resident dietary intake flowsheets for the time period requested
Activities documentation
Activities assessment for the time period requested
Activities progress notes for the time period requested
Resident care plans for the time period requested
Activities participation logs for the time period requested
Additional Documentation:
Advance beneficiary notice (if applicable)
Medicare Secondary Payer (MSP) questionnaire
Once you have compiled your information, it is recommended that a second clinician review the documentation for accuracy. Once approved, you are ready to send off your ADR packet.
Timeliness for this process is of the utmost importance. Medical records received late will result in payment denial or recoupment of payment. This why tracking ADRs is an absolutely necessary process. Make sure you have more than one person who knows this process from start to finish who can step in at a moment’s notice. It is also best practice to have a gatekeeper or response team that is responsible for gathering and reviewing the documents within a timely manner. This person or team must have the authority to hold others accountable and to ensure timely submission of documents to the auditing agency. Don’t get caught in the trap of waiting until the last minute to submit your ADR; mistakes are made in haste.
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.
