Thanks AdvanceMed!

Still working a ZPIC so I am short on time to keep you up to speed.  Luckily, AdvanceMed has done most of my blogging for me tonight.  On a spreadsheet from the Zone, there is a column for the reasons for denial.  Below are some examples.  Read your charts and see if maybe one or more claims could be denied for the same reason.  If the answer is yes, it isn’t too late to do something about it.  Call us!

The documentation provided does not support that the skilled nurse visits are reasonable and necessary. The nurse continued to visit for observation and assessment when there were no acute changes in condition and no changes in the plan of care. There was no documentation of any complicating factors or inherent complex services that would require a skilled professional to be safely and effectively provided. There had been adequate time since start of care of XXXXX to have completed teaching in previous episodes. The medications:  glimeperide, quinapril, atenol, and aspirin are indicated as new on the 485; however, there is no skilled service documented related to these medications.

The documentation provided does not support that skilled nurse visits are reasonable and necessary. The SN continued to visit for observation and assessment when there was no acute change in condition, no new orders, or change in the plan of care. There has been sufficient time since the start of care of xxxx to complete the teaching that was provided in this episode. The documentation provided does not support an exacerbation of the diagnoses as indicated per the 485. There was no documentation of any complicating factors or inherent complex services that would require a skilled professional to be safely and effectively provided. The documentation provided does not support an exacerbation of the diagnoses.

The skilled nurse continued to visit for observation and assessment of patient’s condition when there was no acute change in condition, and no new orders or change in the treatment plan. There was no documentation of any complicating factors or inherent complex services that would require a skilled professional to be safely and effectively provided. The documentation does not indicate that there is likelihood of a change in patient’s condition that requires skilled nursing personnel to identify and evaluate the patient’s need for possible modification of treatment or initiation of additional medical procedures. The records provided do not support an exacerbation of the diagnoses as noted on the 485, or a severity rating of 4 for the arthropathy diagnosis. There has been sufficient time since start of care date of xxxxx to complete teaching.

The documentation provided does not support that the skilled nurse visits are reasonable and necessary. Sufficient time has been allowed to accomplish teaching in previous episodes since the start of care date of xxxx. The nurse provided teaching related to a medication that was not new or changed. The nurse continued to provide observation and assessment when there were no new orders or change in the plan of care. There was no documentation of any complicating factors or inherent complex services that would require a skilled professional to be safely and effectively provided.

The documentation provided does not support that the skilled nurse visits are reasonable and necessary. The skilled nurse provided teaching on hypertension, fall precautions, range of motion exercises to help joint pain and relieve pressure on bony areas, low sodium diet, taking all meds as ordered, and ways to keep BP down. There has been sufficient time since start of care of xxxx in which to have completed this teaching.

So, there you have it.  What you are looking at represents about 2M dollars in denials.

Questions?

.