Harmony Healthcare Blog

Probe, ZPIC, RAC auditors as well as other Medicare Medical Review auditors are quite active throughout the country reviewing PPS and Medicare Part B claims at skilled nursing facility sites.  The request for medical records whether paper or electronic can be a daunting task for providers. Precision and timing are of the essence for a successful review.  CMS considers medical review contractors as being responsible for detecting, deterring, and even preventing Medicare fraud and abuse.  In this capacity, the auditor is directly responsible for operating areas such as investigation, case development, administrative solutions, and referral to law enforcement. 

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Topics: Medical Record Review, Audits,, Denials

One of the easiest problems to solve, but one of the biggest problems existing in long term care is getting industry leaders to recognize the importance of qualified medical records staff. Performing my own, informal root cause analysis this week, I determined that the reason my SNF client was unable to produce a complete medical record for a recent Additional Documentation Request (ADR) was because the medical records staff did not understand what was being asked or expected of them. 

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Topics: Documentation, ADR, Medical Record Review, F-Tags

Skilled Nursing Facility providers have been concerned about potential changes to Section G that would change common interpretation of coding instructions in Section G.  The example cited is as follows:  

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Topics: CMS, Denial Management, Medical Record Review

On May 1,2013 the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule [CMS-1446-P] outlining the proposed Fiscal Year 2014 Medicare payment rates for skilled nursing facilities (SNFs).  The proposed rule outlines an estimated increase in SNF payments of 1.4%.  This estimated increase is attributable to the 2.3% market basket increase, which is then reduced by the 0.5% point forecast error correction, and further reduced by the 0.4% point multifactor productivity adjustment required by law.

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Topics: CMS, Denial Management, Medical Record Review

Often times, clinical records reflect the limited skilled nursing documentation representing the critical thinking of a licensed nurse. The documentation that supports the ongoing skilled nursing care including the risk of exacerbation of medical signs and symptoms. Consider patients who require a continuum of care and may present as medically stable, however, require education and preventative treatment to promote optimal health and wellness. 

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Topics: Medical Record Review, Skilled Nursing Documentation, Skilled Nursing Facility

Over the last 12 months, there have been an inordinate amount of state and federal investigations conducted by ZPIC, OIG, DOJ along with many other governmental entities.  The etiology of these reviews vary in origin, UB-04 edits, diagnoses patterns, ICD-9 Coding, yet a considerable percentage is spurred by whistleblowers.

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Topics: CMS, Denial Management, Medical Record Review

Topics: SNF, OIG, Medical Record Review