Responding to a Home Health Additional Development Request (ADR)

In the April 2010 Medicare Advisory, the RHHI provided the the following list as a recommendation for what to include when responding to a Home Health Additional Development Request (ADR):

Plan of Care and Certification

1. Plan of Care and Certification must be signed and dated prior to billing the end of episode claim.

2. Plan of Care must cover entire billing period.

3. Physician orders not included on the Plan of Care must be signed and dated prior to billing the final claim to Medicare.

4. If alternative signatures are used, submit documentation as outlined in Centers for Medicare & Medicaid Services (CMS) Manual System, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 7, Section 30.2.8.

Documentation of services rendered

1. Adequate documentation is needed to determine medical necessity of all services billed and to support the Health Insurance Prospective Payment System (HIPPS) code (or level of payment) billed.

2. If the medical review for this claim is revenue code specific, you may choose to send notes for the discipline in question, a summary of services rendered or complete field 15 of Form CMS 486 for other disciplines billed; however, all services billed will be reviewed.

3. When intermittency is in question, documentation must include in/out time for nurse and aide visits and the projected endpoint to daily skilled nurse visits. An endpoint statement must include when daily skilled nurse visits are projected to decrease to less than daily.

4. Documentation for all PRN visits, including dates, reason for the PRN visits, outcome of visits and orders for services must be included.

5. Include any other pertinent documentation that may be needed to establish medical necessity (e.g., date of hospitalization, medication changes, laboratory values, physician contacts/visits, etc).

6. Submit documentation denoting treatment week, when different from calendar week.

7. Itemized supply list if billed:

a. Include the quantity and cost of each item.
b. Include physician orders signed and dated prior to billing the end of episode claim to cover all supplies billed.

8. Please send a manifest with medical records submitted and send the medical records in secure packaging to ensure the security of medical records.

9. If responding to multiple requests in a single envelope, ensure each response is clearly separated. If responding to more than one date of service on the same beneficiary, send a response for each request separately. Include a manifest or list identifying each ADR response sent.

10. Attach a copy of the ADR request to each individual claim.

11. Use one staple or elastic band per record to attach the documentation and ADR together. DO NOT use paper clips as they can become dislodged.

12. Do not punch holes in medical records, as this may obscure valuable information.

13. Return the medical records to the appropriate address listed below or on the ADR.

For Postal Delivery Use:
Medicare Part A Medical Review Mail Code: AG-230
P.O. Box 100238
Columbia, Sc 29202-3238

Courier Service, Use:
Medicare Part A Medical Review
Mail Code: AG-230 Building One
2300 Springdale Drive
Camden, South Carolina, 29020-1728

14. Do not include any correspondence other than ADR responses to the medical review department in your envelope.

15. If billing corrections are needed, submit a hardcopy UB-Uniform Billing (latest version from CMS), with a XX7 bill type along with your medical records.

16. Unfortunately, we are not able to accept packages on a C.O.D. basis. Please make sure that you have sent packages with the shipping prepaid.

The Palmetto GBA Medical Review Department developed a Responding to a Home Health Additional Development Request (ADR) checklist. Please complete this checklist and include it when responding to an ADR. This checklist is available on the Palmetto GBA Web site to access this checklist from the Palmetto OBA Web site:

1. Go to www.PalmettoGBA.com/rhhi.

2. Go to the Resources section and select Medical Review

3. Select the Responding to a Responding to a Home Health Additional Development Request (ADR) article.

4. Scroll down to the end of the article and select the PDF document.

Updated address to mail resumees to request Registered Nurse (RN) psychiatric approval for home health visits

PGBA has indicated as of last week that home health agencies should submit the resume of any RN that will be providing psychiatric services under the home health Medicare benefit to the following address:

Palmetto GBA
Medical Affairs, Part A
Mail Code AG-300
P.O. Box 100238
Columbia, SC 29202-3238

10% Cap Outlier Menu Options Available on the Direct Data Entry (DDE) System

According to PGBA, a new inquiry screen has been created in the Direct Data Entry (DDE) system for home health providers which will display the home health payment information that is being accumulated in relation to the 10% cap on outlier payments. Providers may access the information by selecting Option 01 (Inquiries) from the DDE Main Menu and option 67 (Home Health Payment Totals Inquiry) from the submenu. Providers will be required to enter their OSCAR (Provider number) and National Provider Identifier (NPI) to access this information.

The information provided in this article was current as of March 15, 2010. Any changes or new information superseding the information in this article will be provided in articles and publications with publication dates after March 15, 2010 posted at www.PalmettoGBA.com/rhhi.

Therapy Cap Modifier KX Extended Through March 31

On March 2, 2010, President Obama signed into law the “Temporary Extension Act of 2010.” Among other things, this law extends through March 31, 2010, the exception process for therapy claims reaching the annual cap, retroactive to January 1, 2010. Affected providers may submit claims for exceptions to the annual therapy caps, with dates of service January 1 through March 31, 2010, using the KX modifier, following the pre-January 1, 2010, requirements for therapy cap exceptions.