Strategic Health Solutions just posted CMS Therapy Audit Results of one of their outpatient therapy audits. Strategic conducted two audits involving outpatient therapy last summer. The first audit topic was related to therapy stoppage at the end of the year 2012 (or at the cap), and then resumed in the new year (2013). The second audit had to do with therapy provided during Super Storm Sandy. Strategic Health Solutions is a CMS Supplemental Medical Review Contractor (SMRC) and conducted this topical audit by requesting records from 357 providers. The SMRC selected random sample totaled 7,090 claims consisting of 357 unique providers with dates of service August 1, 2012 to March 31, 2013. Additional Documentation Request (ADR) letters were sent to the billing provider. Despite the fact that providers have 45 days to respond to review contractors with the supporting medical record documentation 2580 claims were denied for no response – a 41% error rate just for not responding.
CMS Therapy Audit Results
SMRC noted that they reviewed the claims based on Medicare coverage and documentation requirements described in statue, regulations, and Medicare policy. This is the same manner in which other CMS contractors including the Recovery Auditors and the Medicare Administrative Contractors review claims.
SMRC described the reasons for denial:
- Forty-one percent (41%) of denials were because providers did not respond to the ADR within the 45 day time frame.
- Strategic identified that submitted medical records did not meet documentation requirements for therapy treatment encounter/sessions which are specified in the CMS Internet-Only Manual, Publication 100-02, Medicare Benefit Policy Manual Chapter 15, Section 220.3. This documentation included, but was not limited, to lack of comprehensive evaluation and/or plan of care, identification of specific intervention/modality provided and billed, total timed code treatment minutes, and total time in minutes.
- In addition, submitted medical records did not meet documentation requirements for supporting the number of units of therapy services billed which are specified in the CMS Internet-Only Manual, Publication 100-04, Medicare Claims Processing Chapter 5, Section 20.2.
The SMRC report also included the following statistics of claims, approvals and denials:
SMRC Outpatient Therapy Audit Results
|Number of Claims||Paid||Denied||Error Rate|
|7080||3063||2,580: Denied for No Response|
|1,437: Denied after Review|
|4.014: Total Denied||57%|
The report also included suggestions to providers on how to prevent a denial:
Respond timely to SMRC ADR letters. Submit all documentation related to the services billed which support the medical necessity of the services billed. Report the number of units for outpatient rehabilitation services based on the documented procedure or service. When reporting service units for procedure codes where the procedure is not defined by a specific timeframe (“untimed” procedure), the provider enters “1” in the field labeled units. For untimed codes, units are reported based on the number of times the procedure is performed, as described in the procedure code definition (often once per day). Several procedure codes used for therapy modalities, procedures, and tests and measurements specify that the direct (one on one) time spent in patient contact is 15 minutes. Providers report procedure codes for services delivered on any single calendar day using procedure codes and the appropriate number of 15 minute units of service.
Did you receive an ADR letter from Strategic Health Solutions? Did you respond to the ADR letter? Did you receive a denial or approval? Did you send records timely that were not received and denied?