As a long-term care therapy consultant, I work on a lot of claim reviews and denials management with my clients. I’ve also read a lot of peer-review research articles related to this subject, and have compiled a list of common mistakes that cause denials.
Here’s my top 10 list:
1. Lack of medical necessity – A very subjective statement, but it is usually at the top of everyone’s list
2. Missing signatures –Missed supervisory visits, co-signatures, physician signatures, etc.
3. Coding errors – Technical mistakes related to Part B with KX, 59, and the newer C modifiers
4. Cloning – BEWARE of computerized documentation. It looks great to have these pre-made statements, but if you keep repeating yourself note after note, week after week, it can show lack of medical necessity … and why is the patient still receiving rehab?
5. Duplication – It’s important to document summaries and goals reflecting your scope of practice. If it appears the services were duplicated, the claim may be denied
6. Patient self-discharge – This is tricky because we need to keep our recommendations consistent with our documentation. A patient may stop participating in therapy with little or no notice, so when documenting the discharge summary, clearly explain all therapy recommendations based on their situation.
7. Missed certifications and/or recertifications – Entire claims have been denied because of missing or incomplete Medicare certification forms for Part A patients, or 90-day recertifications missed for Part B.
8. Inappropriate codes – Improper use of modifiers, mistakes in billing and accuracy, MDS coding errors
9. Unsupported ICD-9 codes – Red flag diagnoses, such as, UTI does not require physical therapy, occupational therapy and speech language pathologist service, the medical complexities, co-morbidities, and other conditions exacerbated by the onset of the UTI may result in a change in status with the patient, and that requires PT, OT, and/or SLP services.
10. Incomplete medical records – When claims are requested for review (ADRs (additional documentation request), manual medical reviews, etc.); if they are incomplete upon review, the entire claim may end up denied.
So, where do you fall? In my experience, many of these issues can be resolved with ongoing training and education. Company policies and review processes may also be a helpful tool to prevent and avoid most, if not all, of these areas.
Your therapy staff may be the best of the best and provide excellent treatment. However, if they provide sloppy or poor documentation, your excellent therapy may still end up denied for payment.
Shelly Mesure (“Measure”), MS, OTR/L, is the senior vice president of Orchestrall Rehab Solutions and owner of A Mesured Solution Inc., a rehabilitation management consultancy with clients nationwide. A former corporate and program director for major long-term care providers, she is a much sought after speaker and writer on therapy and reimbursement issues.