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What is an ADR in Home Health?

6/10/2021
by Ed Dieringer, PT, ADR Review Specialist

Stressed Medical Audit

ADR in Home Health

CMS has announced that they will begin issuing ADRs after pausing on ADRs during the Pandemic.  There are very few things as stressful as an ADR.  

At Home Care Answers, we have dealt with hundreds, if not thousands of ADRs, and have had immense success at helping agencies pass them.  In fact, we feel so proud about our record of quality, we will tell you how many denials that we’ve had that are attributable to us.  The Answer:  One.  In 21 years and hundreds of thousands of chart reviews, diagnosis coding, and OASIS audits, we’ve had one denial attributable to us- a coding error from one of our staff.  We’re human.  We’ve made a mistake.  However, we learned from our mistake.  We have since implemented continuous QA protocol that makes sure that QA the coding and OASIS BEFORE the chart arrives in your inbox as complete. 

What is the Full Meaning of ADR?   

An Additional Development Request (ADR) occurs when the payer of a submitted insurance claim requests that the home health agency (HHA) provide supporting documentation to justify payment for a specific period of service.  ADRs can come from a variety of entities - commercial insurers, Medicare, Medicaid, and post-payment government anti-fraud and abuse prevention programs.  We will focus this blog on the most common type of ADR an HHA receives - the pre-payment Medicare Approved Contractor’s (MAC) “medical review” of all documentation related to a patient’s certification period.

ADR Reason Codes

A pre-payment ADR is identified in the Fiscal Intermediary Standard System (FISS) with status/location   S B6001 (not paid) and Reason Code 39700 (Request for ADR).  There are two areas of compliance that the documentation must meet for approval of payment – Technical and Quality of Content.

Medicare ADR Checklist

Here are links and images for several of the MACs ADR Checklist (in addition to the list below)

CGS ADR Checklist (Home Health and Hospice)

Palmetto GBS ADR Checklist PDF

NGS Medicare ADR Checklist

CGS Home Health Checklist

Home Health ADR Checklist – Preferred Order
1.    FISS Page 7 screenprint
2.    Physician Face-to-Face documentation
a. Actual encounter note or progress note
b. Discharge summary from inpatient stay
3.    Plan of care with physician certification/recertifications
a. If recertification, include initial certification
4.    Interim/verbal orders
5.    OASIS assessment
6.    Nursing visit notes
7.    Therapy visit notes including evaluations/re-evaluations
8.    Social work visit notes
9.    Aide visit notes
10.  Other relevant documentation
a. Acute/post-acute care documentation to support home health eligibility.
Link:https://www.cgsmedicare.com/hhh/medreview/adr_process.html
Hospice ADR Checklist – Preferred Order
1.    FISS Page 7 screenprint
2.    Signed election statement
3.    Plan of care with physician certification/recertifications
4.    Physician Face-to-Face documentation (for third and later benefit periods)
5.    Physician orders
6.    IDG reviews/POC updates
 
Note: include reviews for each 15-day period to cover the billing period. This may include reviews/updates that occurred prior to the billing period.
7.    Admission initial assessment
8.    Visit notes (nursing, social worker, chaplain, etc.)
9.    Physician visit notes
10.  Other relevant documentation
Link:https://www.cgsmedicare.com/hhh/medreview/adr_process.html
  • Technical Components
    1. The MAC must receive all documentation listed on page 8 of the ADR within 45 calendar days from the date of notice.
    2. All documents must have the service provider’s signature with professional designation and timely date. If the digital signature and/or date would not be clearly obvious to a reviewer, the HHA should include additional documentation to support the identity, professional designation, and date of the signature.
    3. All documentation must be relevant to the certification period being reviewed.
    4. The primary diagnosis in the initial plan of care and OASIS coding must match the qualified certifying practitioners primary reason for referral and other face to face supporting documentation.
    5. The certifying practioner’s plan of care should contain to the components found at CMS Medicare Benefits Policy Manual (MBPM) Home Health, Chapter 7 Sections 30.2.
    6. All visits must follow the certifying practitioner’s signed plan(s) of care and initial/supplemental orders, including frequency and duration of services.

 

  • Quality of Content Components
    1. Assessments and Daily Notes must demonstrate medically reasonable and necessary “skilled” interventions (MBPM Sections 30.4, 40.1, 40.2).   
    2. Required assessments and reassessments must be timely, supported by “objective observation,” and consistent with other HHA clinicians’ and certifying practitioners’ findings, and support the OASIS. Conflicting or incongruent information between notes should have supplemental orders and/or clarifying documentation by the appropriate clinician added to the patient’s chart and dated as a late entry note prior to sending the ADR.
    3. Daily visit documentation must follow the certified plan of care, be applicable to goals, use medical terms for skilled treatment, and assess the patient’s response to treatment (MBPM - Sections 40.1, 40.2).
    4. All documentation needs to directly or indirectly confirm and, moreover, not contradict Homebound Status. Watch for evolving homebound status regulations each year.  Many medical reviewers will deny payment for non-homebound status when they note that the patient ambulates more than 150 feet.  If you find these words in your HHA documents, carefully review the documentation for safety issues or goal setting rationale to support the reasonableness of continued homebound status.  If this rationale would not be clear to a medical reviewer, the HHA should have the clinician submit clarifying documentation (MBPM - Section 30.1.1).
    5. ADR documentation should be submitted in an orderly fashion, by discipline and dates of services. Clinical summaries of care must clearly demonstrate skilled, reasonable, and medically necessary treatment from the certification/recertification assessments and plan of care to the 30 day summary to the end of the certification period.  Summaries should “tell the story” (MBPM – Section 40.1.1) of observed “material improvement in the patient’s condition” (MBPM - Sections 40.2.1, 40.2.2C), progress toward goals, and adjustments to the plan of care.

An HHA may also receive post-payment ADRs from its MAC.  In these cases, the MAC has created an additional and specific area of review focus as noted in the ADR notice.  MAC post-payment ADR response follows the same procedures as pre-payment ADRs.

An organized, well-presented ADR is the HHA’s singular opportunity to avoid significantly more work and the loss of hard-earned revenues that result from a full or partial denial of payment.  Start early, use a checklist, get clinicians to participate, pay attention to the details, double check everything, and submit the chart information well in advance of the due date. 

In our view, the best defense is a proactive plan, proper documentation, quality coding and OASIS, and an organized plan so when an ADR comes, you don’t panic.  (We wrote a blog about OASIS documentation you can read here.  You simply hand over the documentation knowing it is ready for any audit, which is what we do.  We help agencies get things correct up front, so you don’t have to worry later. 

Home Care Answers is here to help with regular and/or as-needed chart reviews, pre/post-payment ADRs, and Claim Denial Appeals as well as make recommendations to optimize your agency’s revenues and staff time.  We simply want to help.   An ounce of prevention is worth a pound of cure.   We’re 12 ounces of prevention. 

 

Here is a great quick video from CMS on the importance of documentation.  

CMS documentation recap

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