The following is from a denial a client sent last week. The clinical record was originally requested as a routine ADR and payment was denied related to the Face-to-Face document. That denial was overturned in favor of my client but the claim was denied again for a new reason. You have to see this in order to believe it:
Documentation submitted by the provider included a valid face to face encounter form that supported the beneficiary’s skilled need and homebound status. The submitted documentation further suppo1ted skilled nursing services to be reasonable and necessary as evidenced by documentation supported an acute functional and mental decline, recent hospitalization and the need for assessment and observation of condition. However, in review of the physical therapy and occupational therapy evaluations it has been determined the evaluations failed to include short term and long term goals stated in measurable terms with expected dates of accomplishment. Therefore, the six physical therapy visits and the six occupational therapy visits rendered as billed from March 25 to April 12, 2013 will be denied due to invalid/incomplete evaluations.
So, what we end up with a patient that everyone agrees needed services, met Medicare’s eligibility requirements and the agency received no payment because of failure to state long and short term goals.
Did you happen to notice that the entire course of therapy was three weeks?
Have you figured out yet that there were no long/short term goals differentiated on the original chart submitted? That really gets under my skin.
In essence, the denial related to a Face-to-Face document should have never occurred but it did in spite of a perfectly fine document. They agency lost a full round of appeals before the reviewers found something else wrong with the chart. Now the agency is going to the QIC with what amounts to a first round appeal for the PT goals that were never mentioned in the first denial.This example stood out because the reviewer actually wrote that all other requirements were met. I don’t know why she felt compelled to point out how very much the patient’s need for services was supported and payment would have been made save for lack of a long or short term goal. In actuality, there were five of these I worked last week.
You have two choices. First, you can write a short term goal or you can write a very long term goal. The problem with a long term goal is the ability to assess progress towards goals after the patient is discharged. I supposed you could set a goal of swimming the English Channel because I think there is a published list of all who have successfully crossed. Outside of publically available information, how would you verify completion of the goal without violating HIPAA rules?
An alternative solution would be to write a goal or two for the first visit or first week of therapy. Some examples that come to mind from who knows where because I am not a therapist are:
- The patient will agree to participate in their course of therapy by the end of the first visit. (Chances are this is pretty accurate if the patient allows you in for a second visit).
- The patient will have all prescriptions for pain filled prior to next visit. (I do not like the way it sounds when therapists work with un-medicated patients.)
- The patient will have DME delivered by end of day 4 of episode. (If nothing else, this will serve as a reminder to follow up and ensure that DME was delivered.
I have shared this information with several clients who think I have loaned my brain out to someone who needed a laugh. I assure you that is not the case. All of you who receive a denial such as the one described above should include in your argument for payment that whatever new deficiency was identified after the initial denial was overturned was also present in the original submission of documentation. Be bold about it. Include page numbers.
I would be interested to hear what is happening in your offices. Has anyone else seen denials like these? If so, what contractor? (Palmetto, NGS, CGS, etc.) Email me if you don’t want your denials plastered all over the internet or better yet, be loud about them and post them below.