Writing an Appeal Letter

1
Writing an Appeal Letter

• Lisa Werner Bazemore, MBA, MS, CCC-SLP
• Director of Consulting Services

2
Levels in Medicare Appeals Process

• 1. Additional Development Request (ADR)
• Fiscal Intermediary determines whether or not to
  pay the claim.
• 2. Redetermination
• FI considers their original determination based
  on your appeal.
• 3. Reconsideration
• The Qualified Independent Contractor considers
  your appeal.

• 4. Hearing
• The Administrative Law Judge hears your appeal.
• 5. Review
• The Medicare Appeals Council/Department of
  Appeals Board will review the decision of the
  ALJ.
• Next, the Federal District Court will hear you
  case on disputed claims.

The Medicare Appeals Process is the same for
Medicare A and Medicare B claims
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Additional Development Request(ADR)

• Additional Development Request
• Is a written request from the FI for a medical
  record which will be reviewed before payment is
  rendered.
• Frequently comes into the billing office or the
  medical records department.
• Make sure ALL billing and medical records staff
  are aware of what an ADR is and that they have to
  notify you (or delegate) before sending out
  medical records.
• Tips
• Documentation is time sensitive
• Note the source of the document
• Note the reason for the request if one is given
• Be aware
• You have 120 days from the date of receipt of the
  notice. This is presumed to be 5 days after the
  date of the notice.

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Additional Development Request(ADR)

• After you have carefully reviewed the FI
  correspondence
• Follow the directions from the fiscal
  intermediary completely.
• Once the record is copied review it again for
  completeness and accuracy.
• Be sure that each page is copied front and back.
• Make a copy of the packet prior to sending it to
  the FI so you know exactly what the FI had for
  review.
• Send the record to the FI contact as provided on
  the letter using a delivery method that offers a
  tracking number.

5
RAC Exception

• RAC Process
• Charts will be requested and reviewed
• Determination will be rendered and sent to the
  provider
• The provider has 15 days to rebut the decision of
  the RAC before the RAC can request funds from the
  FI
• The RAC will consider the rebuttal
• If payment is denied, they will notify the FI
• Your claim is not a denial until the RAC requests
  funds from the FI
• You have 120 days to appeal the decision from the
  date of the remittance advice

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Redetermination

• The Initial Appeal
• If the FI does not believe that your
  documentation meets their criteria for payment,
  you will receive notification that the claim was
  denied.
• At this stage you will send your record back to
  the FI with a cover letter stating why you
  believe this claim should be paid.

7
Reconsideration

• The initial appeal was considered and denied, so
  now you seek reconsideration with a Qualified
  Independent Contractor
• If the FI rejects your initial appeal, you can
  appeal the claim at the QIC.
• This is the last stage when you can submit new
  evidence, so consider what input may be available
  to strengthen your claim.

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Letters

• You can submit information that will help you
  make your case for payment.
• Types of letters to include
• Letter from the treating physician regarding the
  medical necessity of the stay (ADR cover letter).
• Letter to explain the organization of the medical
  record being submitted. Include for all appeals.
• Redetermination cover letter to rebut the reason
  for the initial denial.
• QIC cover letter to rebut the reason for the
  initial denial and the denial at the
  redetermination stage.
• Letter from the referring doctor to address the
  reason for the referral and perceived necessity
  for rehab.
• Letter from the patient or family member to
  indicate the need and value of the rehabilitation
  stay.

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Preparing the Appeal The Appeal Letter

• The Appeal Letter
• The body of the appeal letter should contain the
  following information
• Discuss the reason for the appeal
• Support the medical necessity of the claim
  according to the conditions of participation
• Defend each week of care
• Explain that the admission was appropriate for
  your level of care and services were reasonable
  and necessary
• Cite specific Medicare regulations such as the
  conditions of participation in your letter where
  applicable

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Preparing the Appeal M.D. Request Letter

• M.D. Request Letter
• Request help from the doctors
• Prepare a form letter to send to the treating
  physician to solicit help with the appeals
  process.
• Explain the reason for the FIs request (probe,
  RAC, program integrity)
• Let the doctor know that their opinion makes a
  difference and carries weight with auditors.
• Provide a template of what to include.
• Indicate a deadline for their letter to be
  submitted to you so you can include it with the
  appeals packet.
• Thank them profusely
• Be prepared to write the letter for them to sign.

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Preparing the Appeal Treating Physicians
Template

• Template should include
• Summary of etiologic diagnosis/reason for rehab.
• Pt. required
• 24 hour availability of rehab MD for _______
• 24 hour availability of rehab nurse for _______
• Multidisciplinary (or interdisciplinary) team
  approach
• Coordinated plan of care
• Intense level of therapy services
• Pt. demonstrated
• Significant practical improvement
• Achieved realistic goals in an appropriate time
  frame (LOS)
• Reason care could not be provided in a SNF

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Preparing the Appeal M.D. Request Letter

• Example of M.D. Cover Letter
• Explain reason for admission
• Ms. Example is a 67 year old female who underwent
  a lumbar decompression and fusion on March 14,
  2007 for spinal stenosis and chronic back issues.
  Her full procedure was that of an L3 through L5
  decompression and fusion from L3 to S1, as well
  as a TLIF at L4-5 and L5-S1. Secondary to this
  surgery and her premorbid condition, she was
  noted to have decreased mobility and inability to
  be independent in ADLs. She had multiple
  comorbidities, including requiring two liters of
  oxygen at night chronically, a history of
  arrhythmias, history of asthma, COPD, and
  depression.

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Preparing the Appeal ADR Cover Letter Example

• Example of ADR Cover Letter
• Review the 8 conditions
• She was evaluated by our preadmission team and
  was felt to be an appropriate candidate for
  rehabilitation. The reason for this was related
  to her recent surgery, long term back issues and
  multiple comorbidities. It was felt that she
  required 24-hour availability of a rehabilitation
  physician, secondary to her respiratory issues,
  hypertension, history of cardiac arrhythmias and
  for aggressive pain management. She also required
  24-hour availability of rehabilitation nursing to
  assist in pain management, monitor her
  respiratory and cardiovascular status, and
  provide education and training in ADL activities.
  Due to the complexity of her back surgery and
  multiple comorbidities, it was felt that she
  required a multidisciplinary team approach with a
  coordinated plan of care at the intense level of
  therapy services that can be found in an acute
  inpatient rehabilitation facility. It was not
  felt that this therapy could have been provided
  at a lesser intense level of care.

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Preparing the Appeal ADR Cover Letter Example

• Provide Therapy Necessity
• Functionally, at the time of admission, she was
  noted to be modified independent for eating and
  she remained so at discharge. Grooming was noted
  to be supervision and she became modified
  independent at discharge. Bathing was moderate
  assistance and was supervision at discharge.
  Upper extremity dressing was noted to be minimum
  assistance on admission, modified independent at
  discharge. Lower extremity dressing was maximum
  assistance on admission and supervision at
  discharge. Toileting was moderate assistance on
  admission and minimal assistance at discharge.
  With respect to bowel and bladder management, she
  was at a modified independent level at admission
  and remained so at discharge. Transfers from the
  bed to wheelchair were minimum assistance at
  admission and modified independent at discharge.
  Toileting and tub and shower transfers were noted
  to be minimum assistance at admission and
  supervision on discharge. With regard to
  locomotion she was noted to be maximum assistance
  for walking at admission and modified independent
  at discharge. Stairs were noted to be maximum
  assistance on admission and modified independent
  at discharge.

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Preparing the Appeal ADR Cover Letter Example

• Provide Medical Necessity
• From a medical standpoint, she was monitored
  closely with respect to her pain management.
  Medications were adjusted, including adding other
  modalities such as Lidoderm patch and TENS
  trials. She also had the addition of Neurontin to
  address the neuropathic component of her pain.
  Overall her pain management was improved
  throughout her stay. Her cardiac status was
  monitored. She was maintained on her Digitek and
  Isoptin and blood pressures were monitored as
  well. Also, she was kept on her antihypertensives
  from admission. Regarding her respiratory status,
  she was kept on oxygen at night. She did have
  frequent documented episodes of desaturation to
  the mid 80s on room air with exertion and
  therefore required supplemental oxygen at
  discharge. Her depression was monitored as well
  and she was maintained on Effexor.

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Preparing the Appeal ADR Cover Letter Example

• Summarize Findings
• Overall, from a medical standpoint with the close
  medical management and rehabilitation nursing,
  she did well in that area. It should also be
  noted that she remained anemic throughout her
  stay with her hemoglobin both on admission and
  discharge varied from 8-9 mg/dl. She was treated
  with iron supplementation and Epogen. From the
  functional standpoint, as can be seen above, she
  improved significantly throughout her
  rehabilitation stay in a relatively short period
  of time. She was subsequently discharged to home
  with her family. In my opinion, Ms. Example was
  treated in the most appropriate setting for her
  rehabilitation needs and it is not likely that
  she would have achieved such medical improvements
  and stability during her rehabilitation course
  without the assistance of a rehabilitation
  physician and a rehabilitation nurse. In
  addition, without the assistance of the
  multidisciplinary team, I dont believe she would
  have had such excellent functional improvements
  during her stay that allowed her to return back
  to her home setting within a week.

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Preparing the Appeal ADR Cover Letter Example

• Provide Additional Resources
• Additionally, we have provided appendices for
  your reference for the tabulation of therapy
  minutes (Appendix A) and how our medical records
  are organized (Appendix B).
• Please do not hesitate to contact me if you have
  any questions or need clarification.

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Preparing the Appeal ADR Cover Letter Example

• Appendix B Excerpt
• Before the tabs begin you will find the
  following
• Inpatient Admission Record contains demographic
  information
• IRF- PAI (Inpatient Rehabilitation Facility -
  Patient Assessment Instrument)
• Coding Summary Form
• A summary for each tab is listed below
• White Tab Admission
• Request for Treatment Authorization
• Advance Directives Acknowledgement Form
• Pre-admission Assessment
• Referring Hospital Therapy Notes (if available)

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Preparing the Appeal Redetermination
RequestLetter

• After initial determination denial, write a
  redetermination request
• The request should detail how the claim meets
  medical necessity for the reasons sited for
  denial.
• Consider presenting proof on all 8 conditions of
  participation

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Preparing the Appeal Redetermination Request
Letter Example

• Reasons for Denial
• To Whom it May Concern
• The above referenced claim was denied at
  determination due to the following four (4)
  reasons
• The documentation submitted did not demonstrate
  the intense level of rehabilitation services were
  provided to the patient.
• The documentation submitted did not reflect the
  degree of physician involvement, which is
  normally only rendered in a hospital setting.
• The documentation did not reflect the need for
  24-hour availability of a registered nurse with
  specialized training/experience in
  rehabilitation.
• The documentation submitted indicated the patient
  could have achieved his improvement in a less
  intensive setting.
• For your review, enclosed is a complete copy of
  the medical records, numbered on the lower right
  corner of each sheet from Page 1 to 593. The
  Provider respectfully requests that all of these
  documents be carefully reviewed. When the record
  is reviewed in its entirety Providers claim is
  properly supported and should be paid.

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Preparing the Appeal Redetermination Request
Letter Example

• Patient Summary
• In summary, Mr. X is a 92-year old gentleman who
  suffered a clinical stroke that left him with an
  objective left facial droop dysarthria, dysphasia
  and right-sided in-coordination and was admitted
  to Carolinas Rehabilitation from 11/24/06 through
  12/15/06. Premorbidly the patient was in his
  normal state of health independent with
  communication cognition, mobility transfers and
  activities of daily living. His case was
  reviewed by our consult physiatrist and was
  determined to be appropriate for inpatient
  rehabilitation as this is the most appropriate
  setting for his recovery from his stroke. It was
  also determined that he required 24 hours
  availability of a rehabilitation physician as
  well as a rehabilitation nurse or management in
  light of his dementia, hypertension, COPD and
  history of alcohol and tobacco abuse.

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Preparing the Appeal Redetermination Request
Letter Example

• Patient Summary (continued)
• Mr. X required and received a comprehensive
  interdisciplinary stroke specialized
  rehabilitation program that included
  rehabilitation patient therapy, occupational
  therapy, speech therapy, medical social worker,
  therapeutic recreation services and medical
  psychology services. A formal team conference
  led by a physiatrist occurred on a twice weekly
  basis to insure a program of care. Mr. X
  participated in an intense occupational and
  physical therapy program that allowed him to
  achieve his established goals in a reasonable
  time. Unfortunately, due to a lack of family
  support for ongoing assistance, the patient
  subsequently was discharged on 12-15-06 to a
  sub-acute skilled nursing facility for ongoing
  decreased level of supervision and care.

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Preparing the Appeal Redetermination
RequestLetter Example

• Regulation Citation and Rebuttal of Denial
• Denial Rebuttal
• 1. The documentation submitted did demonstrate
  the intense level of rehabilitation services were
  provided to the patient.
• Pursuant to Medicare Benefit Policy Manual,
  Chapter 1, 110.4.3, the Provider either provided
  and the beneficiary received at least 15 hours of
  combined therapy per week or documented that the
  patient had a condition which prevented such
  participation in therapy. Furthermore, Medicare
  Benefit Policy Manual, Chapter 1, 110.1 requires
  that determinations of medical necessity for IRF
  services be based upon an assessment of each
  patients individual needs and prohibits denials
  of payment based on numerical utilization
  screens, diagnostic screens, diagnosis or
  specific treatment norms, the three hour rule,
  or any other rules of thumb.

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Preparing the Appeal Redetermination
RequestLetter Example

• Mr. X required an intense level of therapy
  services as evidenced by the pre-admission
  document that can be found on pages 11-17. An
  intense level of services was ordered in the
  admission orders on page 50-52. Mr. X
  participated in therapy as per the grid in
  Appendix A. He received 1080 minutes in week 1
  and 1260 in week 2 and 1260 in week 3. This
  indicates that Mr. X received more than the
  required amount of therapy.

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Preparing the Appeal Redetermination
RequestLetter Example

• Denial Rebuttal (Regulation Citation and Rebuttal
  of Denial, continued)
• 2. There was sufficient documentation to
  substantiate close medical supervision by a
  physician with specialized training or experience
  in rehabilitation.
• Pursuant to Medicare Benefit Policy Manual,
  Chapter 1, 110.4.1, the Provider demonstrated
  that the patient required the 24-hour
  availability of a physician with special training
  or experience in the field of rehabilitation as
  evidenced by entries in the patients medical
  record that reflect frequent, direct and
  medically necessary physician involvement in the
  patients care i.e., at least every two to three
  days during the patients stay.
• Mr. X required the oversight of a rehabilitation
  physician for management of his functional and
  medical needs. His medical complications
  included recent stroke, hypertension, COPD,
  urinary tract infection, and sleep disturbance.
• Mr. X required frequent intervention for the
  following diagnoses
• Nutritional compromise we consulted nutrition
  who assisted with ensuring Mr. X had proper
  nutritional intake.

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Preparing the Appeal Redetermination
RequestLetter Example

• Urinary tract infection we diagnosed this
  infection on November 27th. A UTI in an elderly
  person can significantly impair their cognitive
  and functional condition. It was important to
  monitor Mr. X closely to ensure he was able to
  continue to participate in his rehabilitation
  program.
• Hypertension which was a contributor to his
  stroke, was an issue during his rehab stay. We
  monitored his pressures closely and determined an
  adjustment to his Norvasc dosing was required.
  Once the dose was adjusted we continued to
  monitor to ensure the change was effective. We
  also monitored the patients neurological status
  as he was at significant risk for a second
  stroke.
• Sleep disturbance we prescribed Trazodone for
  Mr. Xs sleep disturbance and monitored his
  response. He needed to have adequate sleep so he
  could participate in the full benefit of his
  therapies. Additionally we monitored the amount
  of time he slept with a sleep log to ensure the
  treatment was effective.
• In addition to managing the medical complications
  detailed above, I coordinated the plan of care
  for nursing and therapy.

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Preparing the Appeal Redetermination
RequestLetter Example

• Denial Rebuttal (Regulation Citation and Rebuttal
  of Denial, continued)
• 3. There was documentation to validate the
  requirement of 24-hour availability of a
  registered nurse with specialized training or
  experience in rehabilitation.
• Pursuant to Medicare Benefit Policy Manual,
  Chapter 1, 110.4.2 the facility demonstrated
  the patient required the 24-hour availability of
  a registered nurse with specialized training or
  experience in rehabilitation through the
  comprehensive rehab nursing documentation found
  in the Nursing documentation sections as well as
  in the multidisciplinary team meetings.

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Preparing the Appeal Redetermination
RequestLetter Example

• Mr. X required the 24-hour availability of a
  rehabilitation nurse to treat the following
• Skin integrity concerns due to decreased
  mobility, hemiparesis and nutritional deficits
  treated by nursing via daily skin assessments,
  application of prescribed medications and
  pressure ulcer prevention techniques.
• Safety concerns due to weakness, hemiparesis, and
  cognitive deficits. Interventions included
  frequent monitoring and assistance with mobility.
• Nutrition and hydration issues in light of recent
  cerebrovascular accident. He was treated with
  rehabilitation nursing education, nutritional
  consult and prescribed medications

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Preparing the Appeal Redetermination
RequestLetter Example

• Knowledge deficit in the areas of nutrition,
  safety, medication management, complications of
  diagnoses, advanced directives, pain, patient
  rights and responsibilities, infection control,
  and self care. Education on these items was
  provided during his entire stay and evidence can
  be found on pages 565-567.
• Mobility and self care deficit was treated by
  nursing by carryover of therapy techniques during
  outside of therapy. Nursing documentation of
  therapy carryover can be found in the
  rehabilitation nursing documentation and in the
  interdisciplinary FIM document on pages 91-128.
• In ordering rehabilitation nursing at Carolinas
  Rehabilitation it was known that nursing would
  perform daily assessment and intervention on fall
  risk, neurological checks, psychosocial status,
  respiratory status, cardiovascular status,
  gastrointestinal status, renal status, bowel and
  bladder status, mobility, wound care, pain,
  safety and intake and output monitoring.
  Assessment and intervention on these items can be
  found in the daily nursing documentation.

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Preparing the Appeal Redetermination
RequestLetter Example

• Denial Rebuttal (Regulation Citation and Rebuttal
  of Denial, continued)
• 4. The documentation submitted indicated the
  patient could not have achieved his improvement
  in a less intensive setting.
• Pursuant to Medicare Benefit Policy Manual,
  Chapter 1, 110.4 Rehabilitative care in a
  hospital, rather than in a SNF or on an
  outpatient basis, is reasonable and necessary for
  a patient who requires a more coordinated,
  intensive program of multiple services than is
  generally found out of a hospital. A patient
  probably requires a hospital level of care if
  they have either one or more conditions requiring
  intensive and multidisciplinary rehabilitation
  care, or a medical complication in addition to
  their primary condition, so that the continuing
  availability of a physician is required to ensure
  safe and effective treatment.

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Preparing the Appeal Redetermination
RequestLetter Example

• As can be seen from a review of the medical
  record, Mr. X had significant medical
  comorbidities prior to and during his rehab
  admission that required frequent and direct
  interventions from the physiatrist and
  rehabilitation nurse. Based on this and his
  functional needs, it was appropriate to admit him
  into an acute inpatient rehabilitation facility.
  When it became apparent his family would not be
  able to care for him in the community and he no
  longer needed the 24 hour availability of a rehab
  physician and nurse he was discharged to a
  skilled nursing facility as was appropriate.

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Preparing the Appeal Redetermination
RequestLetter Example

• Regulation Citation and Additional Information
• Additional Information
• Pursuant to Medicare Benefit Policy Manual,
  Chapter 1, 110.4.6 hospitalization after the
  pre-admission screening is covered only in those
  cases where the pre-admission screening results
  in a conclusion by the rehabilitation team that a
  significant practical improvement can be expected
  in a reasonable period of time. It is not
  necessary that there be an expectation of
  complete independence in the activities of daily
  living, but there must be a reasonable
  expectation of improvement that is of practical
  value to the patient, measured against the
  patients condition at the start of the
  rehabilitation program. Mr. Xs pre-admission
  assessment on pages 11-17 indicated inpatient
  rehabilitation was the most appropriate setting.
  In rehabilitation his progress from maximal to
  moderate assistance with most functional
  activities and mobility progressed to moderate to
  minimal assistance with most functional
  activities (please see therapy evaluation on page
  485-487 and discharge summary on pages 483-484
  for complete functional results) was significant
  in that it lessened the burden of care to his
  caregivers.

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Preparing the Appeal Redetermination
RequestLetter Example

• Pursuant to Medicare Benefit Policy Manual,
  Chapter 1, 110.4.7 the most realistic
  rehabilitation goal for most Medicare
  beneficiaries is self-care or independence in the
  activities of daily living i.e.,
  self-sufficiency in bathing, ambulation, eating,
  dressing, homemaking, etc., or sufficient
  improvement to allow a patient to live at home
  with family assistance rather than in an
  institution. Additionally the Policy Manual
  states the aim of the patients treatment is to
  achieve the maximum level of function possible.
  Review of the physical therapy and occupational
  therapy evaluation on pages 485-487 shows the
  patients assessment levels as requiring physical
  assistance with the majority of self care and
  mobility items. Page 487 of the evaluation shows
  the goals established as supervision for most
  functional independence measure items. Achieving
  this level of independence would have enabled Mr.
  X to return to the community with supervision.

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Preparing the Appeal Redetermination
RequestLetter Example

• Conclusion
• I do not believe that Mr. X could have received
  this required care at any other setting other
  than an acute inpatient rehabilitation facility.
  The patient, in my opinion, was most
  appropriately treated at an intensive
  rehabilitation level of care and, in my opinion,
  would have more than likely had significant
  medical complications and worse functional
  outcome if treated at a lower level of care.
• Please also see attached Appendix A - a
  spreadsheet that summarizes the amount of
  combined therapy the beneficiary received and
  Appendix B - a guide to the structure of the
  medical record.
• We respectfully request that you render a
  favorable decision so that Carolinas
  Rehabilitation may receive Medicare payment for
  the above-referenced claim. Should you need any
  further information or documentation, please do
  not hesitate to contact me. Thank you.
• Respectfully, Winning Doctor, MD, Carolinas
  Rehabilitation

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Preparing the Appeal Supporting Letters

• Consider letters from the referring M.D. and the
  patient
• Referring M.D.
• Send a letter from the attending rehab doctor
• Remind them of the patient and your screening
  process to validate the patients selection
• Explain the FIs activity in your facility and
  area
• Let them know how and why you are proceeding with
  the appeals process
• Underscore the importance of maintaining access
  to care and your facilitys mission
• Write the letter for the doctor and list why
  rehab was necessary

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Preparing the Appeal Supporting Letters

• Patient
• Send them a letter at denial, assuring them they
  will not have to pay
• Explain the FIs activity in your facility and
  area
• Let them know how and why (because the denial was
  an error) you are proceeding with the appeals
  process
• Underscore the importance of maintaining access
  to care and your facilitys mission
• Ask them to write a letter saying why they needed
  inpatient rehab
• Have them send you the letter so you can use in
  the Redetermination, Reconsideration, and above.

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The Medical Record

• Where do you find this information in your chart?
• Is that a really good question?

38
Physician Documentation

• Purpose
• Establish medical necessity
• Clearly state why the patient needed to occupy an
  inpatient rehabilitation bed
• Indicate why the patient requires an intense
  level of rehabilitation services
• List problems and services that are needed
• Define why patient could not have their needs met
  in a skilled nursing facility
• AND
• Document information required to ensure
  continuity of high quality care

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Physician Documentation

• Whats so special about Physical Medicine and
  Rehabilitation?
• Combining into one Plan of Care
• Medical treatments
• Therapy treatments
• Three levels of documentation quality
• Basic Some documentation of therapy status and
  goals in the same document as medical status
• Advanced Documentation about therapy treatment
  status, plan and goals in the same document as
  the medical treatment plan
• Exemplary Links medical and therapy issues so it
  is clear how the two are interrelated

40
Physician Documentation

• Review the physicians documentation for evidence
  of
• Conditions and comorbidities addressed
• Evidence of complications that were prevented due
  to medical care
• Guidance and leadership provided to the nurses
  and therapists
• Comments on how medical complications impacted
  functional progress
• Notes on interactions with consulting physicians
  and changes to medical or functional plan based
  on the consultation.
• Medical care rendered that would not be provided
  in a less intense level of care

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Team Documentation

• Look for documentation of skilled services
• Consider reporting summaries of use of examples
  where skilled terminology and objective
  measurements were in documentation to show
  functional progress and improved safety.
• Examples include
• Assessment of performance
• Adaptation of the task or environment
• Training in the use of adaptive equipment
• Use of specialized treatment techniques
• Adjusting the treatment program as the patient's
  condition changes
• Providing analysis of performance and skilled
  feedback on performance

42
Team Documentation

• Look for documentation of skilled services
• Documentation that the patient was able to follow
  directions, retain the skills learned, and show
  carryover of the learned skills into other
  functional areas.
• Justification of the need to continue treatment
  based on progress, treatment goals, and
  functional level needed at discharge.
• Explanation of setbacks or lack of progress while
  supporting that the patient retained good
  potential to achieve the set goals.

43
Team Documentation

• Team has an ongoing opportunity to document
  medical necessity. Did they document?
• That services needed were of a complex nature
  that they required a licensed clinician
• Services were consistent with diagnosis, need,
  and medical condition
• Services were consistent with the treatment plan
• Services were reasonable and necessary
• Patient was making progress towards reasonable
  goals

44
Nursing Documentation

• Items that show that rehabilitation nursing
  services were necessary 24/7
• Nursing plan addresses rehabilitation needs of
  the patient
• Supports medical management as laid out by
  physician
• Addresses education needs of the patient
• Establishes continuity of care among the team

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Nursing Documentation

• Showing progress
• At least weekly, return to the established team
  goals.
• Note where progress has been made by stating
  current status compared to prior status.
• Review previous narrative notes to determine what
  burden of care was present earlier that is now
  resolved.
• Indicate how nursing interventions resulted in a
  positive outcome.

46
Therapy Documentation

• At least weekly, a summary of the patients
  progress should be documented.
• Document progress toward goals
• Detail barriers to achievement of goals
• Describe changes to the plan of care as
  appropriate
• Describe patients response to treatment
• State the justification for continued stay on the
  rehab unit

47
Therapy Documentation

• Common Treatment Areas
• Normalize muscle tone
• Facilitate functional movement patterns
• Improve coordination
• Improve postural control, kinesthesia, and
  proprioception
• Documentation
• Indicate the specific techniques rendered (e.g.,
  NDT, PNF, Feldenkreis)
• Explain how these techniques affect muscle tone
  and improve balance, coordination, posture,
  proprioception, and kinesthetic sense
• Example
• NDT and PNF techniques used to normalize
  hypertonic left UE and facilitate controlled
  voluntary movement in functional patterns. This
  was followed by PNF in bilateral reciprocal
  combined D1 and D2 diagonals to achieve minimal
  assistance with donning and doffing a jacket.

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Therapy Documentation

• Common Treatment Areas
• Self-Care Dependence
• Will be noted in such areas as eating, bathing,
  dressing, maintaining hygiene
• May be due to
• Decreased strength
• Marked muscle spasticity
• Moderate to severe pain
• Contractures
• Incoordination
• Perceptual motor loss

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Therapy Documentation

• Common Treatment Areas
• Mobility Dependence
• Will be noted in such areas as transfer, gait
  deviation, stair climbing, and wheelchair
  maneuvering
• May be due to
• Decreased strength
• Marked muscle spasticity
• Moderate to severe pain
• Contractures
• Incoordination
• Perceptual motor loss
• Orthotic need
• Need for ambulatory or mobility device

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Therapy Documentation

• Common Treatment Areas
• Safety Dependence/Secondary Complications
• May manifest in the performance of activities of
  daily living or to acquired secondary
  complications that could intensify medical
  sequelae such as fracture nonunion, or decubiti.
• Some examples of safety dependence are high
  probability of
• Falling
• Swallowing difficulties
• Severe loss of pain or skin sensation
• Progressive joint contracture
• Infection requiring skilled PT intervention to
  protect the patient from further complication

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Appeals Tracking

• What eRehabData tracks
• Type of request
• Dates of correspondence with the FI
• Dates of responses from the FI
• Reason for denial
• Payment/denial amounts

• How we report it
• Active appeals
• Closed appeals
• Total cases in appeal at each stage
• Total dollars in dispute at each stage
• Total dollars paid at each stage
• Total dollars denied at each stage

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Appeals Tracking

• Data Repository
• Allows you to upload medical records for storage
  in eRehabData
• Can keep records in storage for later review
• Others can access records with the proper
  privileges
• Assistance with appeal preparation can occur from
  remote locations

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Words of Wisdom

• Words of Wisdom
• Appeal all claims
• Track all claims
• Adhere to time frames
• Receive information from Business/Finance Office
  in a timely manner
• Respond in a timely manner with the correct
  documents
• Review carefully all documents from the FI
• The ADRs may come in quickly and in large numbers
• Have a system to make the process flow smoothly
• Appoint a person or two to write the initial
  appeals to gain proficiency. Proficiency yields
  efficiency.

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Thanks

• Thank you to Carolinas Rehabilitation in
  Charlotte, NC, for the examples provided and
  their willingness to share with all of us what
  they perfected during their experience with a
  Fiscal Intermediary Probe Audit.
• Thank you to Suzanne Snyder who prepared many of
  these slides for original use in the Supporting
  Medical Necessity workshop sponsored by
  eRehabData.

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Questions?

• Lisa Werner Bazemore, MBA, MS, CCC-SLP
• Lbazemore_at_erehabdata.com
• 202-588-1766