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Appealing a Denial for Skilled Therapy Services

Appealing a denial for skilled therapy services can be a daunting task rife with stress.
However, most Fiscal Intermediaries (FIs) or Medicare Administrative
Contractors (MACs) send specific guidance on information they need to see in a
denial. As this information sometimes differs, the following is an outline of
general information that many have found to be helpful.  

It is common for denials to result from billing coding errors or claims that include diagnoses
that fall outside the Local Coverage Determination (LCD). The LCD is a document
that outlines the criteria for reasonable/medically necessary skilled therapy
services defined by the FI/MAC.  In some cases, denials may be due to incomplete
billing, such as a claim lacking the modifier applied to the CPT code. Denials
can also result from inadequate supporting documentation that has been submitted
in response to an Additional Documentation Request (ADR).

 

Audit contractors are instructed to deny services if they meet any of the following
conditions.

  • The item or service does
    not fall into a Medicare benefit category.
  • The item or service is
    statutorily excluded.
  • The item or service is
    not reasonable and necessary.
  • The item or service does
    not meet other Medicare program requirements for payment.

 Auditors must adhere to CMS issued national coverage determinations (NCDs) and regional local coverage determinations (LCDs). In the absence of NCDs or LCDs, the contractors
are responsible for determining whether services are reasonable and necessary,
based on the following criteria.

  • It is safe and effective.
  • It is not experimental or investigational.
  • It is furnished in accordance with accepted standards of practice for the diagnosis or treatment of the beneficiary's condition.
  • It is provided in a setting appropriate to the beneficiary's medical needs and condition. It is ordered and performed by qualified personnel.
  • It meets, but does not exceed, the beneficiary's medical need.

Auditors can review any documentation submitted with the claim, other documentation
subsequently submitted by the provider, or billing history obtained from
Medicare databases. Any information submitted by the provider must corroborate
the documentation in the beneficiary's medical record and confirm that Medicare
coverage criteria have been met.

In general, information that is important to incorporate into the denial letter includes:

  1.  Nursing notes that support the
    functional level of the patient and the ongoing need for therapy.
  2. Physician skilled certifications (for Medicare Part A patients).
  3. Documentation from other disciplines that may support cognitive/communicative difficulties experienced by the
    patient.
  4. Dietary consultations that may support the presence of swallowing disorders.
  5.  Hospital History and Physical to add medical diagnoses that serve as complexities to the case.

An expanded, detailed summary of progress from the start of care should be compiled. The summary should include both objective data and other supporting information that may not have been contained in the original documentation. Think of this process as a painting, where the  therapy services that were rendered are only a part of a larger picture. Try to write the appeal as an explanation of why the services were rendered, what could have happened if they weren't rendered, and what functional outcomes the patient achieved because of the services.

A best practice is for Corporate Compliance to 1) Analyze the denial and the associated documentation to determine how to best write the appeal; 2) Write the denial appeal with input from the therapist and the therapist’s careful review of the completed document. Individual providers may utilize a different process based on infrastructure, internal expertise, and other factors.

It is important to remember that the issuers of denials are not typically therapists. They are trained auditors who determined, for whatever reason, that the services rendered were not reasonable and/or medically necessary.

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