ADR Checklist

Make no mistake that what I am about to say is shameless self promotion.  The safest way to ensure that any medical records requested by a payor source meet standards are to have them reviewed by someone with experience and who does not know the patients or the agency.  This doesn’t always ensure payment but it can alert you to your vulnerabilities so that you can make a plan before the next dance with your MAC.

Short of the the level of security offered by Haydel Consulting Services, you can do your own reviews.  More important than the actual content of the review is the attitude of the person doing the review.  Attacking the charts like a rabid Pit Bull will ensure that most errors are identified but Pit Bulls do not implement action plans.  Your reviewer needs to be cognizant of the fact that any errors or omissions identified are  tools to help cover their coworkers back and they need to be willing to help out their colleagues.  If they can be ethically corrected, they should be.  If they cannot, a team with members from every part of the organization needs to implement a plan to prevent repeat errors.

Here is what I look for:

1. Orders signed and dated by physician.
2. Face to face in all charts.
3. Medications
4. Diagnoses – note meds came first.  Are there any meds for dx’s not listed.
5. Frequency – does it correspond to the patients’ needs?
6. Functional status – if the patient is minimally impaired in the functional domain, are they homebound for psychiatric reasons?
7. Is teaching original and relevant?
8. If re-teaching is present, is the reason why re-teaching was necessary explained?
9. Does teaching require the skills of a nurse?  It does not require the skills of a licensed nurse to tell a patient to take medications timely.
10. ARE THERE ORDERS FOR THERAPY?
11. Are therapy re-evals done on schedule?
12. Is there any lab or other diagnostic tests that support care for the patient even if they were performed in a prior episode?
13. If subcutaneous injections are given, is there a reason why the patient cannot be taught?
14. Is there a documented predictable end to daily skilled visits when daily nursing visits exceed 21 days?
15. If the patient is seen for Management and Evaluation, is an RN performing the visit?
16. If Observation and Assessment is documented as a skill, are there any clear indications that the patient is likely to become unstable?
17. Are patient and clinician signatures consistent throughout the record?
18. Are there any hospital or MD reports that will support services?
19. Does the clinical note contents support OASIS?
20. Is the primary diagnosis the focus of care?

Notice again that two questions that are critical to payment are asked last.  It is only after reading the entire episode that you can truly answer these questions.

There are so many other important elements in a chart that are required in order to reflect good clinical care.  This is a payment review only.  So, if the patient had 12 nursing visits scheduled and two were missed, that will not affect payment but I want to go on record as saying that it is unacceptable to find out about two missed visits on ADR review.

If you find egregious mistakes that cannot be ethically corrected, back out the claim.  For instance, if there were no therapy orders after the initial order to evaluate and treat, back out the claim and resubmit it less the therapy.  Print all paperwork and send it with the ADR.  This will not prevent a denial but you won’t look stupid either.  After that, find the therapist culprit and violate your work place violence policy.

I am very interested in knowing who is getting denied for what.   Please email me privately if you have the goods.

And if you are not pleased with what you are finding, do not hesitate to call us.