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Medicare ADR Checklist

6/4/2021
by Keith Grunig

What is an ADR Letter?

We've all received them.  The dreaded letter.  The MAC gave you an ADR.  With the pandemic winding down, CMS has announced that it will be resuming post payment audits.  An ADR letter is a letter from the MAC asking for additional information called Additional Development Request.  There are different types of reasons.  Regardless of the reason, agencies must respond to the request in a certain time frame.  The letter will inform the agency of what they are looking for and when to submit the information.   

We have written a previous blog answering what an ADR is.  You can read that link here.  It is loaded with great information from ADR expert Ed Dieringer, PT.  He has developed expertise in all things ADR.  Auditing, appealing, and education.  He is a physical therapist by trade, but has owned and operated home health and hospice agencies in the past and developed a deep understanding of ADRs, regulations, and how to appeal (and win) where possible.  

Many people ask for an ADR checklist.  There is a lot of information needed when responding to an ADR.  At the end of the day, documentation will make or break the agency.  Quality documentation that shows, in detail, medical necessity, progress to goals, and following the plan of care will be the way that agencies are not denied- so long as the basic  stuff is taken care of like signed and dated plan of care with credentials from the referring physician.  We have a blog that talks about OASIS documentation, you can read that here.  

Medicare ADR Checklist

Because we deal with all of the MACs and agencies in multiple states, we are familiar with where to find information.  Come to find out, it's not always easy to find the information you're looking for when you have an ADR.  

We have compiled the links from all three MACs on their 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

We thought that the CGS Checklist was the cleanest and most concise of the links.  

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

 

By having complete and correct documentation and records, you will be able to handle ADRs when they come.  We have handled thousands of them in the past.  In the history of the company, we have had only one denial attributal to us- a coding error several years ago.  We're human, we made a mistake.  We can help you remain compliant by getting OASIS and coding correct- which then allows you to have everything else ready.  We'll help you pass with flying colors.  

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