Medicare issues a widespread prepay review for Rehab Services in LA and MS!
Part A Providers
Date
July 28, 2010
To:
All Louisiana/Mississippi Outpatient providers – Administrators, Business Office Manager and Medicare billing departments
From:
Pinnacle Business Solutions, Inc.
Purpose
The purpose of this advisory is to notify providers that Medical Review will be conducting a widespread prepayment probe review of therapy services in the outpatient setting. Claims will begin suspending the first week in July with reason code 5PESA.
Reason for the Probe
Therapy services are a new problem area on the FY2010 Strategy for Louisiana Part A and Mississippi Part A.
There were 55 CERT errors for RC 042X, 043X, and 044X in Louisiana and Mississippi from 4/01/2007 through 4/30/2009 due to insufficient documentation submitted and services incorrectly coded. There were no errors for TOB 13X for RC 044X
Louisiana/Mississippi exceeds the nation by dollars per beneficiary and units per beneficiary for outpatient billing on therapy revenue codes 042X, 043X, and 044X based on claims processed through December 2009.
Current data is for paid dates November 2009 through April 2010. Revenue code 042X ranks 20th by allowed dollars among all revenue codes for TOB 13X and accounts for 55.6% when billing 97110. Revenue code 043X ranks 32nd by allowed dollars among all revenue codes in TOB 13X and accounts for 34.7% when billing HCPCS 97110. Revenue code 044X ranks 36th by allowed dollars among all revenue codes in TOB 13X and accounts for 39.9% when billing HCPCS 92507.
Requested Information
Medical Policy Parameter (MPP) 5P001 and 5P002 will be set up in the Fiscal Intermediary Standard System to suspend targeted claims to status location S B6001 where an electronic Additional Documentation Request (ADR) will be attached. The ADR will be on page 7 of the suspended claim. You will have 45 calendar days to submit the requested medical records.
The ADR will request the following documentation for each claim:
1. Physician’s order for therapy
2. Therapy initial evaluation/re-evaluation
3. Plan of care or treatment plan
4. Physician/NPP Certification/Re-certification
5. Treatment encounter notes for every treatment day and every therapy service including the following:
a. Date of treatment
b. The name of the treatment, intervention, or activity provided
c. Type of equipment used
d. Time spent in services represented by timed codes
e. Total treatment time (including the untimed service codes)
f. Signature and professional identity of qualified professional who furnished or
g. Supervised and list of each person contributing to treatment during that encounter
h. Record and justification of any changes
· If treatment is added
· If treatment changed
· Between the interval progress reports
6. Progress Reports
7. Interpretation of abbreviations used in therapy notes
8. Initial date of service
If there is any question as to the legibility of a signature on any of the documentation, a signature verification form with a signed and printed name may be obtained and submitted with the ADR response. If a signature is missing from any documentation, an attestation statement may be obtained and submitted with the ADR response. If a signature is missing or illegible, the reviewer will conduct the review without considering the documentation with the missing or illegible signature.
To ensure accurate receipt and logging of your records, please attach a copy of the ADR on top of each individual record being submitted. Please note that the claims must be separately identifiable by Medicare number (HICN) and dates of service.
The requested information will be medically reviewed to ensure correct payment of the claims and in compliance with Medicare guidelines. The results of the probe review will be published once the review of all medical records is complete.
Denial of Claims
If the medical records are not received within 45 calendar days, the claim will automatically deny with reason code 56900. It is your responsibility to check the status of the claim to ensure that records are received and logged into the system. For further consideration of payment, the claim must go through the appeals process, which delays payment. We urge you to submit ALL requested documentation in a timely manner.
Medicare has the authority to collect information for the audit of records. Title XVIII of the Social Security Act, Section 1833 (e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim. Failure to submit requested medical records will result in complete denial of services and may result in exclusion from participating in any federal health care program according to the Social Security Act, Section 1128 (B)(11).
Should you have any questions regarding this bulletin, please call us at 337-993-5730 or 888-922-6227, or you can send us your questions via e-mail by using the Contact Us feature on our Web site.