ACHM President’s Message 2017-03-29T15:50:47+00:00

Dear Colleagues,

Hyperbaric oxygen therapy is going through unprecedented scrutiny. OIG work plan for 2017 includes HBO therapy on top of the list. Most of medicare intermediaries are conducting prepayment review or prior authorization at present time.

Let us look at the top 10 reasons for denial in prepayment review:

  1. No Documentation of Medical Necessity.
  1. Dependent services denied (For e.g. Surgical procedure was denied as documentation did not support medical necessity, therefore all other charges cannot be allowed and will be denied as dependent to the medical denial of the qualifying service).
  1. No valid plan of care and the plan of care must be established before rendering treatment.
  1. The recommended protocol was not ordered or followed.
  1. One or more requirement for local coverage determinations were not met
  1. No physician’s order.
  1. Units billed more than ordered – The physician’s orders submitted did not cover all of the units billed.
  1. Services not documented.
  1. Requested records not submitted in timely fashion.
  1.  30 day standard of care not documented or provided.

How to avoid and respond to a denial:

  1. Submit all documentation related to the services billed which support the medical necessity of the services.
  1. A legible signature is required on all documentation necessary to support orders and medical necessity.
  1. Use the most appropriate ICD-10-CM codes to identify the beneficiary’s medical diagnosis.
  1. All documentation to support orders, documentation of services rendered and documentation of medical necessity for the qualifying services for the date(s) billed.
  1. These services must be furnished under a written plan of care and the plan of care must be established before rendering treatment.
  1. At a minimum, the plan of care should include (1) the diagnosis, (2) long term goals, and (3) type, amount, duration and frequency of the specific therapy service.
  1. Documentation should include:
  • Clear physician’s order with indication of need, dose, frequency and route.
  • Relevant history and physical and/or progress notes.
  • Clear indication of the diagnosis.
  • Clinical signs and symptoms.
  • Prior treatment and response as applicable.
  • Stage of treatment as applicable.
  • Documentation of administration.
  • A physician’s order should be submitted for review with the request for copies of medical records.
  • A legible signature is required on all documentation necessary to support orders and medical necessity.
  • The copy of the order should be legible and dated.
  • Make sure any orders submitted for review are for the dates of service billed.
  1. Submit all documentation related to the services billed.
  1. Ensure that records submitted are for the date of service billed.
  1. Submit the medical records as soon as the ADR is received. The Provider has  45 days from the date the ADR is received.

I  am hope you will benefit from the steps listed above. As Helen Keller quoted,

“Alone we can do so little; together we can do so much.”

 

Until next time,
Dr. Jayesh Shah,
President of ACHM