Harmony Healthcare Blog


Posted by Kris Mastrangelo on Wed, Jun 23, 2010

Edited by Kris Mastrangelo


An additional development request (ADR) is a window of opportunity to provide what the FI needs to pay a claim.  If you let that window close without anteing up the requested back-up documentation, your facility will end up with lots of claim denials.

Denial Management:  Harmony recommends the following steps when filing an appeal of a denied additional development request claim with the Fiscal Intermediary:

1.  Highlight specific content on each document which supports skilled care provided.

For example:  MD notation that a patient is making progress and should continue with Therapies, social service note which summarizes skilled stay and successful discharge to targeted environment.

2. Review the entire record for documentation from all disciplines that supports skilled care for the period being denied.

3. Include documentation from the 7-day (or 14 if applicable) look back period. This information is the basis for why the team continued to provide skilled care.

4. Write a formal narrative letter and submit with all appeals explaining why skilled care was reasonable and necessary during the denied dates of service. Please see the attached examples of Medicare Part A and Part B appeal letters.

5. The best why to avoid nursing denials is proactive daily documentation of skilled services provided.

6. Therapy denials are avoidable with daily notations of each modality provided with weekly narrative notes summarizing skilled intervention. Documentation that states the therapist's expectation that the patient will continue to succeed toward set goal areas / revised goal areas.

The current denial concerns a patient with Multiple Sclerosis.  Key Areas for nursing documentation for patients with Multiple Sclerosis include:

1. Bladder dysfunction and complications and related risk factors including recurrent urinary tract infections, skin breakdown, incontinence and bladder spasticity.  

2. Bowel dysfunction including constipation from decreased bowel motility and medications used to treat MS, weakened abdominal muscles, general weakness and immobility as well as fecal incontinence. Include risk factors such as skin breakdown, and bowel obstruction.

3. Visual Impairment such as double vision can cause dizziness and contribute to fall risks.

4. Impaired Mobility can include decreased balance and coordination, paralysis, tremor and weakness. Spasticity can hamper gait, seating and comfort. Spasticity and paralysis can also contribute to muscle contractures, decreased joint range of motion and pressure areas.

5. Fatigue can exacerbate other symptoms of MS including cognitive dysfunction and can contribute to fall risk.

6. Pain including neuralgia, tonic spasms, optic neuritis, extremity pain - usually a nagging burning pain and complex regional pain syndrome. Pain has an impact on mood and this should be addressed as well.

7. Psychosocial needs including self esteem and maintaining relationships with family and friends. Also depression, feelings of helplessness and risk for suicide need to be assessed and monitored.

Complete Guide to Successfully Avoiding Denied Claims


Tags: ADR

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