In 2020 there was a lull in Medicare Administrative Contractors (MACs) and Recovery Audit Contractors (RACs) requesting medical records for audits through August 2020.
Audits have resumed, including audits under the Targeted, Probe, and Educate (TPE) process. The most recent TPE focus involves Medicare Part B review of therapy claims billing CPT codes 97530 (therapeutic activities) and 97110 (therapeutic exercises) and Medicare Part A skilled nursing claims from 2017 through 2019 with admitting diagnoses of urinary tract infection and/or sepsis.
Are you confident that your Part B provider’s documentation clearly supports that the codes and number of units billed based upon the patient’s unique skilled needs, including one-on-one care, was provided? For Skilled Nursing Facility (SNF) Medicare Part A claims under Resource Utilization Groups (RUGS) IV, does the facility’s documentation support the RUG level billed? Remember, the review period is for patient stay claims provided prior to the Patient Driven Payment Model (PDPM) implementation of 10/1/2019.
A review of the previously conducted Novitas JH TPE SNF Round One results notes the following denial reasons:
- Medical necessity of skilled services.
- Certifications/re-certifications incomplete or missing.
- Insufficient documentation to support three-day qualifying stay.
- Therapy documentation submitted for review does not reflect the level of intense therapy provided as reasonable and necessary.
- Missing therapy evaluations and physician’s documentation to support RUG codes billed.
- Missing therapy documentation of plan of care and treatment notes for look back period and billing RUG codes not calculated in the Minimum Data Set (MDS) system.
- Incorrect Assessment Reference Date (ARD) dates billed, benefits exhausted.
Novitas JL TPE for therapy Medicare Part B services lists the following denial reasons:
- Medical necessity could not be fully supported because documentation was lacking evidence of a certified/re-certified plan of care by the ordering/treating practitioner.
- Insufficient documentation was provided to support the services billed to Medicare. In some instances, there was no response to the ADRs (documentation was not submitted to Novitas in a timely manner to support the services billed to Medicare).
Will Your Documentation Pass a Probe?
Medical necessity must be supported to meet conditions of Medicare payment. The documentation must clearly demonstrate that the care provided was medically reasonable and necessary. This is required whether the patient is treated under Medicare Part A or Medicare Part B.
Although SNFs are now under PDPM for reimbursement, there have been no changes in the documentation requirements to demonstrate the medical necessity of the services provided by therapy providers. The therapy documentation should clearly support the patient’s clinical category reported by the facility.
Should claims be denied as the result of an audit, are you prepared to appeal the claims? LWCI can help!
- LWCI has highly skilled and knowledgeable consultants with extensive denial response experience not only for federal payers but also commercial payers.
- LWCI conducts external objective documentation and coding audits that support practices’ commitment to an effective compliance plan and serves as a preventive measure for denied claims.
LW Consulting, Inc. can assist you with your compliance program and/or conduct a documentation and coding audit. For more information, contact Deborah Alexander at 717-213-3122 or email DAlexander@LW-Consult.com.