What is one of the top reasons for therapy claim denials? Poor documentation? Incomplete documentation? Missing documentation?  Believe it or not, incomplete submission of necessary documentation when submitting an ADR (Additional Development Request) packet is one of the most common ADR denial reasons we receive.

When the Medicare contractor doesn’t receive complete ADR packets, down coding of the RUG level is the most common error made by providers which calculates into more resources to appeal, and a negative impact on cash flow.

Below are some tips to avoid down code of the RUG Level:

1. Submit all documentation to support the RUG code(s) billed. This includes:
   1. Therapy service logs containing actual therapy minutes delivered
   2. MDS assessments with nursing documentation to support the ADL score
   3. Therapy clinical documentation
      1. Physician signed & dated therapy orders for all disciplines
      2. Physician signed & dated therapy plan of care for all disciplines
      3. Daily notes and weekly notes to establish the medical necessity of the services

2. Ensure the information submitted supports the medical necessity for the services:
   1. Include all documentation to support the medical necessity of the services billed.
   2. Submit documentation for the entire look back periods.  This may include up to 30-45 days PRIOR to the dates of service under review.

Gina Tomcsik

Director of Compliance

Functional Pathways

[email protected]