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First Round of PDPM ADRs Arrive


Operating under PDPM is now the ‘new normal’, and the industry – as a whole – is performing well under the new system! However, it’s time for a reality check.


Industry thought leaders anticipated that CMS audits would come. And no surprise, CMS has indicated they are looking at several specific areas of the medical record including medical necessity, ICD-10 coding accuracy, ensuring that clinical documentation supports cognitive decline, swallowing deficits/altered diet, depression, and Section GG coding.


Having a tight process in place will help providers tackle additional development requests (ADRs) immediately upon arrival. Considerations include: Be sure that front-desk and billing staff know to look for ADRs arriving by regular mail, or posted in the online system operated by your MAC (FISS or DDE). Review the ADR and make note of the submission deadline as these can vary depending on the type of audit/payor.


Assemble an ADR Response Team now before an ADR is received to compile records and documents specific to department/predetermined assignment, and ensure timely submission. Your response team should consist of MDS, nursing, billing, and therapy team members.

Notify your Rehab Director as soon as an ADR has been received. Therapy documentation may be integral in supporting various sections of the MDS, including Sections K, O, GG, I and C. Your Rehab Director should have access to necessary resources and assist in preparation.


Before submitting, review all documentation to ensure technical requirements have been met (i.e. timely signature, valid certifications, etc.) Use an ADR Document Checklist to assist in compiling the packets, ensure they are complete, and support the HIPPS codes billed. If you don’t have a checklist, contact HealthPRO Heritage to receive our checklist tool.


Pay close attention to ADR specific instructions: For example, most ADR’s contain a bar-coded coversheet that must be placed on top of the records for submission. ADR cover letters that outline services provided during the time period in review are not required but can may be included at the discretion of the ADR Response Team.


ADDITIONAL NOTE: In addition to ADRs, CMS has alerted SNF providers RE: a claims issue regarding the Variable Per Diem (VPD) adjustment. If claims are not processed in date order, the VPD will not calculate correctly. CMS is expected to correct this issue in October, but please be sure to check your remittance statements for any errors.


Submitted by David Mercugliano, Sr. Vice President for Business Development, in collaboration with the Clinical Strategies Division at HealthPRO Heritage


More information: https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-02-27

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