MDS Alert

Published on Tue Feb 02, 2010 PDF

The supporting Part B documentation should identify the decline in function.

If your RAC readiness program for Part B doesn't prevent or fix these key issues before billing, it may need some quick rehabbing of its own.

1. Non-compliance with the Medicare contractor's local coverage decisions. "Some FIs/MACs have local coverage decisions where they won't pay a particular CPT code without a certain therapy treatment diagnosis code being on the claim," says Victor Kintz, MBA, CHC, LNHA, RAC-CT, CCA, managing director of operations for The Polaris Group based in Tampa, Fla. "Those omissions will be easy ones for RACs to find," Kintz warns.

2. Documentation shortfalls. Part B therapy is vulnerable to complex reviews by RACs in the area of medical necessity, says Nancy Beckley, MB, MBA, CHC, a consultant with Bloomingdale Consulting Group Inc. in Brandon, Fla.

Must do: "The supporting Part B documentation should identify the decline in patient function," advises Kintz. "Hopefully the nurses' notes speak to the decline in function prior to the initiation of therapy services, as well." The medical record and therapy evaluation should also clearly state the patient's prior level of function, he adds. "It's not enough to state that the person is in the nursing home."

Also: "Identify the reason for the therapy referral and if the patient has previously received therapy for the same condition," advises Beckley. Suppose a patient has a chronic condition, such as Parkinson's or Alzheimer's disease and has been treated for it previously. In that case, the therapist has a "duty to differentiate why skilled therapy is needed again and what it is going to accomplish," says Beckley. "If you have a patient who makes two steps forward with therapy and takes two steps backward when therapy stops -- that person may not be appropriate for therapy," Beckley adds. However, "there are exceptions where an intervening event such as a fall or acute illness may have caused the decline," she adds. If the patient isn't a candidate for therapy, he may still be a candidate for restorative nursing.