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.

Contact Richter Healthcare Consultants

Do you have questions about Additional Development Requests (ADR) or have managed care audit defense challenges? Call Richter's clinical healthcare consultants at 866-806-0799 to schedule a free consultation. 

Jennifer Leatherbarrow, RN BSN, RAC-CT, QCP, CIC is a Clinical Consultant with Richter Healthcare Consultants.