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Medical Review (MR) FAQs

Ambulance

1. Do we issue an advanced beneficiary notice (ABN) to a beneficiary who chooses to be taken to a hospital 30 miles further than the closest appropriate facility because that is where his family physician practices?

Blepharoplasty, Blepharoptosis and Brow Lift

1. I have had Blepharoplasty, Blepharoptosis and Brow Lift claims denied for lack of documentation. What are the documentation requirements for these procedures?

Bone Mass Measurement

1. What is the correct way to code a patient that is postmenopausal when having a Bone Mass Measurement?

Medical Records Submission

1. If a single beneficiary's claims suspend for medical review, for multiple dates of service, can one set of documentation be submitted or do we need to submit documentation to support each bill that suspended?

Medical Review Denials

1. My claim was denied and the only reason I received was the denial code on my Remittance Advice (RA). How can I get more specific denial information?

Inpatient Psych Facilities

1. When the physician documents a recertification, should the progress note specifically state "recertification"?
2. What timeframe must the recertifications follow?
3. Can we continue to bill Medicare for services if we have a patient that is ready for discharge but at the time, there is not a safe facility available to discharge them to?

Inpatient Rehabilitation Facility

1. Can non-physician practitioner/physician extenders write orders in an IRF?
2. Can non-physician practitioner/physician extenders sit in on the IRF Team Conferences?
3. Where can I find a listing of the classification criteria for an Inpatient Rehabilitation Facility?
4. What documentation is required for Inpatient Rehabilitation Facility (IRF) Team Conferences according to CMS regulations?

Skilled Nursing Facilities

1. Is it acceptable for Physical Therapy (PT) Assistants or Occupational Therapy (OT) Assistants to sign the MDS?
2. Can therapy treat on the day of discharge when the patient is remaining in the facility? For example, the discharge is planned for 6/27 but the provider could not complete the discharge paperwork until 6/28.
3. When is a delayed certification for Medicare Part A services acceptable?
4. How do I bill for SNF services when the beneficiary is out of the facility at midnight on a leave of absence (LOA)?
5. Is there a written list of the types of services that are considered skilled?
6. Can patients admitted to the SNF from an inpatient psychiatric hospital qualify for skilled services?
7. Are beneficiaries that are tube fed always considered skilled patients? Do they ever receive another benefit period?
8. If the Minimum Data Set (MDS) (ARD) was set within the appropriate timeframes, but was not transmitted to the State timely, can the facility still bill the appropriate RUG code once the MDS is completed and transmitted, even if it is late, or must they bill at the default rate only?
9. If a patient is on a leave of absence, is the day of that leave reimbursable to the SNF?
10. Could you explain what is meant by the lookback period in SNF services?

Therapy

1. Do we need to have the therapist's signature on the daily grid (service log) that reports minutes?
2. What is the correct way to bill if treatment time for three different modalities add up to 18 min? For instance, 7 minutes of gait training (HCPCS 97116), 5 minutes of therapeutic exercises (97110) and 6 minutes of massage (97124) were provided in one session.
3. How do we bill timed and untimed therapy codes?
4. Do we need to record time in and time out for outpatient therapy services?
5. Is functional electrical stimulation (Vital Stim) covered for the treatment of dysphagia?
6. Is an evaluate and treat order written by the physician acceptable for the therapist (PT, OT, SLP) to perform an evaluation and begin treatment immediately or is something else required?
7. When is it appropriate to bill a re-evaluation verses an initial evaluation? For example, a patient is receiving physical therapy due to a total knee replacement and during this time period he falls and fractures his wrist. The patient now needs therapy on his wrist in addition to the knee therapy.
8. When performing outpatient physical therapy, occupational therapy, or speech-language pathology services, is the therapist required to perform and bill a re-evaluation every 30 days for a patient who requires therapy services longer than 30 days?

Ambulance

1. Do we issue an advanced beneficiary notice (ABN) to a beneficiary who chooses to be taken to a hospital 30 miles further than the closest appropriate facility because that is where his family physician practices?
   In any emergent situation, the patient is considered to be under duress and therefore an ABN should not be issued. ABNs should only be issued in non-emergent situations. Ambulance suppliers may develop their own process to communicate to beneficiaries that they will be billed for excluded services for which the ABN is not appropriate.

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Blepharoplasty, Blepharoptosis and Brow Lift

1. I have had Blepharoplasty, Blepharoptosis and Brow Lift claims denied for lack of documentation. What are the documentation requirements for these procedures?
   The medical record must include patient complaints and findings secondary to eyelid or brow malposition; frontal photographs; visual fields testing and physician interpretation demonstrating a difference of 12° or more or 30% superior visual field difference. The amount of improvement must be documented in specific, measurable terms.
   
   Medical Review Documentation Guidelines
   
   WPS Medicare LCD for Blepharoplasty, Blepharoptosis and Brow Lift (L29973)

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Bone Mass Measurement

1. What is the correct way to code a patient that is postmenopausal when having a Bone Mass Measurement?
   The ICD-9 code V49.81 is specific to natural, age related menopause. Beneficiaries with a history of surgical menopause should be billed under ICD-9 code V45.77- acquired absence of genital organs. For additional information on the appropriate codes please see WPS Medicare LCD for Bone Mass Measurement (L31620).

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Medical Records Submission

1. If a single beneficiary's claims suspend for medical review, for multiple dates of service, can one set of documentation be submitted or do we need to submit documentation to support each bill that suspended?
   Since we conduct an independent review of each suspended claim, a separate set of the records needs to be submitted for each requested period of service billed. This applies to multiple requests for the same beneficiary.

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Medical Review Denials

1. My claim was denied and the only reason I received was the denial code on my Remittance Advice (RA). How can I get more specific denial information?
   For specific reasons for denial of medically reviewed claims (such as what documentation was missing or why the service was not medically reasonable and necessary), please contact our Customer Service department. Please have your claim information ready so your inquiry can be forwarded to Medical Review for an appropriate response. Contact Customer Service at 866-518-3285.

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Inpatient Psych Facilities

1. When the physician documents a recertification, should the progress note specifically state "recertification"?
   You do not have to make a red flag to say recertification, but you do need to have all of the necessary components to support the recertification. The recertification should state that:
   • inpatient psychiatric hospital services furnished since the previous certification or recertification were, and continue to be, medically necessary for either treatment which could reasonably be expected to improve the patient's condition or a diagnostic study AND
   • the hospital records indicate that the services furnished were either intensive treatment services, admission and related services necessary for diagnostic study, or equivalent services. CMS IOM Publication 100-1, Chapter 4, Section 10.9Adobe Portable Document Format

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2. What timeframe must the recertifications follow?
   First recertification is required no later than the 12th day of hospitalization. The second recertification is required by no later than the 18th day. Subsequent recertifications must be made at intervals established by the utilization review committee (on a case by case basis), but in no event may the interval between recertifications exceed 30 days. CMS IOM Publication 100-01, Chapter 4, Section 10.9Adobe Portable Document Format

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3. Can we continue to bill Medicare for services if we have a patient that is ready for discharge but at the time, there is not a safe facility available to discharge them to?
   Payment for inpatient psychiatric hospital services is to be made only for active treatment that can reasonably be expected to improve that patient's condition. Services without active treatment would be considered custodial in nature. CMS IOM Publication 100-2, Chapter 2, Section 20Adobe Portable Document Format

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Inpatient Rehabilitation Facility

1. Can non-physician practitioner/physician extenders write orders in an IRF?
   Non-physician practitioner/physician extenders may write orders and participate in team conferences (with the caveat that they don't take the place of the physician. Non-physician providers (effective January 1, 1998) had restrictions removed on the type of areas and settings for which they can be paid. They can write orders in all settings in which they receive Medicare payments (assuming their state licensure allows them to do so.) CMS IOM Publication 100-4, Chapter 12, Section 120Adobe Portable Document Format.

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2. Can non-physician practitioner/physician extenders sit in on the IRF Team Conferences?
   If the non-physician practitioner wants to sit in on the care conference, that is OK, but the physician must participate in the Team Conference. A very important component of the medical necessity criteria for IRF admission is that the patient must require the 24 hour availability of a physician with special training or experience in the field of medical rehab. Thus, at a minimum, the multidisciplinary team that meets to assess and evaluate the patient'' condition should consist of a physician, a rehab nurse and one therapist. This section of the regulations should not be interpreted in any way to mean that a non-physician practitioner could substitute for the physician, especially since the physician is required to be actively involved in the patient's care. CMS IOM Publication 100-2, Chapter 1, Section 110.2.4Adobe Portable Document Format

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3. Where can I find a listing of the classification criteria for an Inpatient Rehabilitation Facility? (IRF)
   CMS Internet Only, CMS IOM Publication 100-4, Chapter 3, Section 140Adobe Portable Format document

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4. What documentation is required for Inpatient Rehabilitation Facility (IRF) Team Conferences according to CMS regulations?
   To meet CMS IOM Publication 100-2, Chapter 1Adobe Portable Document Format, Section 110 the following documentation must be submitted for Team Conferences in order for IRF services to be considered reasonable and necessary. Multidisciplinary Team Conferences are a way of monitoring the complex medical condition of the patient's progress. Weekly Multidisciplinary Team Conferences are a requirement and must be led by a Rehabilitation Physician who is responsible for decisions during the patient's hospital stay in the IRF. The team members are to include Rehabilitation Physician, Rehabilitation RN, Social worker/Case manager and licensed therapist from each discipline. The conference note should have the documented team members name and their professional designation. For additional information see Medical Review Documentation Guidelines The Multidisciplinary Team Conferences must consist of the following components:
   • Assessing the patients progress
   • Identify problems with resolution
   • Reassess the validity of the goals
   • Monitor and revise the plan of care as needed

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Skilled Nursing Facilities

1. Is it acceptable for Physical Therapy (PT) Assistants or Occupational Therapy (OT) Assistants to sign the MDS?
   Yes, according to the RAI Manual, all persons participating in the completion of the MDS should sign it. However, Section R of the MDS must be signed by the Registered Nurse (RN) coordinating the assessment.
   • PARTICIPANTS IN THE ASSESSMENT PROCESS
     

     Federal regulations require that the RAI assessment must be conducted or coordinated with the appropriate participation of health professionals. Although not required, completion of the RAI is best accomplished by an interdisciplinary team that includes facility staff with varied clinical backgrounds. Such a team brings their combined experience and knowledge together for a better understanding of the strengths, needs and preferences of each resident to ensure the best possible quality of care and quality of life. In general, participation by all relevant interdisciplinary team members will encourage more active and appropriate assessment and care planning processes.

     Facilities have flexibility in determining who should participate in the assessment process as long as it is accurately conducted. A facility may assign responsibility for completing the RAI to a number of qualified staff members. In most cases, participants in the assessment process are licensed health professionals. It is the facility's responsibility to ensure that all participants in the assessment process have the requisite knowledge to complete an accurate and comprehensive assessment. RAI Manual(external link), Chapter 1

   • AA9. Signatures of Persons Completing These Items
     Coding: All staff responsible for completing any part of the MDS, MPAF, and/or tracking forms must enter their signatures, titles, sections they completed, and the date they completed those sections. Read the Attestation Statement carefully. You are certifying that the information you entered on the MDS, MPAF, and/or tracking form is correct. Penalties may be applied for submitting false information. RAI Manual(external link), Chapter 3

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2. Can therapy treat on the day of discharge when the patient is remaining in the facility? For example, the discharge is planned for 6/27 but the provider could not complete the discharge paperwork until 6/28.
   If the beneficiary was discharged on 6/27, then the skilled therapy services would end on that day. The discharge paperwork should be finished on the day of the planned discharge. Payment for Part A services would end on the discharge day. No skilled days are utilized on the discharge day. The facility would still report any therapy services but there would be no additional reimbursement for those services. CMS IOM Publication 100-4, Chapter 6, Section 40.3.5 Adobe Portable Format document

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3. When is a delayed certification for Medicare Part A services acceptable?
   

   "Skilled nursing facilities are expected to obtain timely certification and recertification statements. However, delayed certifications and recertifications will be honored where, for example, there has been an isolated oversight or lapse.

   In addition to complying with the content requirements, delayed certifications and recertifications must include an explanation for the delay and any medical or other evidence which the skilled nursing facility considers relevant for purposes of explaining the delay. The facility will determine the format of delayed certification and recertification statements, and the method by which they are obtained. A delayed certification and recertification may appear in one statement; separate signed statements for each certification and recertification would not be required as they would if timely certification and recertification had been made." CMS IOM Publication 100-1, Chapter 4, Section 40.5Adobe Portable Document Format - Delayed Certifications and Recertifications for Extended Care Services

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4. How do I bill for SNF services when the beneficiary is out of the facility at midnight on a leave of absence (LOA)?
   A leave of absence occurs when the beneficiary is absent, but not discharged, from the SNF, at midnight. Leave of absence days are shown on the bill with revenue code 018X and LOA days as units. However, charges for leave of absence days are shown as zero on the claim, and the SNF cannot bill the beneficiary for them. CMS IOM Publication 100-4, Chapter 6, Section 40.3.4 and 40.3.5.2Adobe Portable Format document

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5. Is there a written list of the types of services that are considered skilled?
   There is no written list of the services that are considered skilled, however, there are many references that help to define skilled services. The Medicare Benefit Policy Manual, CMS IOM Publications 100-2 Chapter 8, Section 30Adobe Portable Document Format defines skilled services. The Resident Assessment Instrument RAI Manual(external link) helps facility staff gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan. It also assists staff to evaluate goal achievement and revise care plans accordingly by enabling the facility to track changes in the resident's status. The RAI simply provides a structured, standardized approach for applying a problem identification process in long-term care facilities.

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6. Can patients admitted to the SNF from an inpatient psychiatric hospital qualify for skilled services?
   

   While a 3-day stay in a psychiatric hospital satisfies the prior hospital stay requirement, institutions that primarily provide psychiatric treatment cannot participate in the program as SNFs. Therefore, a patient with only a psychiatric condition who is transferred from a psychiatric hospital to a participating SNF is likely to receive only non-covered care. In the SNF, the term "non-covered care" refers to any level of care, which is less intensive than the SNF level of care, and is covered under the program. CMS IOM Publication 100-2, Chapter 8, Section 20.1Adobe Portable Format document

   In order for admissions to a skilled nursing facility, for psychiatric services, to be considered for coverage, the services provided must support the need for skilled services that can only safely and effectively be provided in a skilled nursing facility.

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7. Are beneficiaries that are tube fed always considered skilled patients? Do they ever receive another benefit period?
   Enteral feedings that comprise at least 26 percent of daily calorie requirements and provide at least 501 milliliters of fluid per day are considered a direct skilled nursing service. As long as the beneficiary continues to receive enteral feedings that comprise at least 26 percent of daily calories and 501 milliliters of fluid per day, they are considered skilled. If the beneficiary remains in the skilled nursing facility and continues to meet the tube feeding requirements, they will exhaust their 100 benefit days and will not be able to start another benefit period until 60 consecutive days have passed during which he/she is not an inpatient of the SNF or the feeding requirements drop below the skilled level of care requirements for 60 consecutive days. CMS IOM Publication 100-2, Chapter 8, Section 30.3Adobe Portable Format document

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8. If the Minimum Data Set (MDS) Assessment Reference Date (ARD) was set within the appropriate timeframes, but was not transmitted to the State timely, can the facility still bill the appropriate RUG code once the MDS is completed and transmitted, even if it is late, or must they bill at the default rate only?
   The provider must submit the MDS to the State system before a claim is submitted for payment to Medicare. If the provider has not submitted the MDS to the state, a claim cannot be submitted to Medicare for payment, even at the default rate. Once the MDS has been submitted to the state, even if it is late, the bill may be submitted to Medicare. RAI Manual(external link), Chapter 6

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9. If a patient is on a leave of absence, is the day of that leave reimbursable to the SNF?
   If a patient begins the leave of absence and returns before midnight the same day, the day of the leave is reimbursable to the SNF. However, if the patient has not returned to the SNF by midnight of the day of leave, that day is not reimbursable to the SNF. The non-reimbursable leave days do not count against the beneficiary's 100 day SNF benefit, but do count as part of the "episode of care" period. They should be billed included in "Non-covered Days" under Revenue Code 018X. Occurrence span code 74 is used to report the dates the leave began and ended. Please refer to CMS IOM Publication 100-2, Chapter 8, Section 30.7.3 and 60Adobe Portable Format document

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10. Could you explain what is meant by the lookback period in SNF services?
    The look back or observation period is the 7, 14 or 30-day period prior to and ending on the ARD date. It is the time period during which data about the patient's condition is documented and included in the Minimum Data Set (MDS) assessment. SNF PPS payments rates are based on the patient's condition determined by classification into a specific Resource Utilization Group (RUG) which are based on an assessment reference date and various look back periods. The MDS is required to be performed according to an established schedule for purposes of Medicare payment.
    
    For further SNF Regulations see: CMS IOM Publication 100-8, Chapter 6, Section 6.1Adobe Portable Document Format
    
    For information on SNF Documentation Guidelines see our Medical Review Documentation Guidelines page.
    
    For further SNF requirements see : RAI Manual(external link).

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Therapy

1. Do we need to have the therapist's signature on the daily grid (service log) that reports minutes?
   The staff that provides the service should initial the log.
   Signature and professional identification of the qualified professional who furnished or supervised the services and a list of each person who contributed to that treatment (i.e., the signature of Kathleen Smith, PTA, with notation of the help of Judy Jones, PT, supervisor, when permitted by state and local law). The signature and identification of the supervisor need not be on each Treatment Note, unless the supervisor actively participated in the treatment, but the supervisor's identification must be clear in the Plan of Care, or Progress Report. When the treatment is supervised without active participation by the supervisor, the supervisor is not required to cosign the Treatment Note written by a qualified professional. When a supervisor is absent, the presence of a similarly qualified supervisor on that day is sufficient documentation and it is not required that the substitute supervisor sign or be identified in the documentation. Since a clinician must sign the Progress Report, the name and professional identification of the supervisor shall be included in the Progress Report. CMS IOM Publication 100-2, Chapter 15, Section 220.1.1E Treatment NoteAdobe Portable Document Format

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2. What is the correct way to bill if treatment time for three different modalities add up to 18 min? For instance, 7 minutes of gait training (HCPCS 97116), 5 minutes of therapeutic exercises (97110) and 6 minutes of massage (97124) were provided in one session.
   One unit of gait training would be billed since the total minutes of therapy are enough to qualify for one unit and the majority of the minutes were spent on gait training.

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3. How do we bill timed and untimed therapy codes?
   If the service being provided does not fall under a timed code, it can only be billed as 1 unit.
   
   Example 1 - HCPCS 97001 (PT Evaluation); even if the Initial Evaluation takes 30 minutes, only 1 unit may be billed and the time does not count towards total treatment time for timed codes.
   
   Example 2 - HCPCS 97032, electrical stimulation (manual), each 15 minutes is a timed code and application from 8 to 22 minutes would be counted as 1 unit.
   
   Counting Minutes for Timed Codes in 15 Minute Units

   When only one service is provided in a day, providers should not bill for services performed for less than 8 minutes. For any single timed CPT code in the same day measured in 15 minute units, providers bill a single 15-minute unit for treatment greater than or equal to 8 minutes through and including 22 minutes. If the duration of a single modality or procedure in a day is greater than or equal to 23 minutes through and including 37 minutes, then 2 units should be billed. Time intervals for 1 through 8 units are as follows:

   Units	Number of Minutes
   1 unit:	> or = 8 minutes through 22 minutes
   2 units:	> or = 23 minutes through 37 minutes
   3 units:	> or = 38 minutes through 52 minutes
   4 units:	> or = 53 minutes through 67 minutes
   5 units:	> or = 68 minutes through 82 minutes
   6 units:	> or = 83 minutes through 97 minutes
   7 units:	> or = 98 minutes through 112 minutes
   8 units:	> or = 113 minutes through 127 minutes

   The pattern remains the same for treatment times in excess of 2 hours.
   If a service represented by a 15 minute timed code is performed in a single day for at least 15 minutes, that service shall be billed for at least one unit. If the service is performed for at least 30 minutes, that service shall be billed for at least two units, etc. It is not appropriate to count all minutes of treatment in a day toward the units for one code if other services were performed for more than 15 minutes. CMS IOM Publication 100-4, Chapter 5, Section 20.2Adobe Portable Format document

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4. Do we need to record time in and time out for outpatient therapy services?
   Reporting of actual therapy time is essential to ensure accurate billing of therapy services. However, in accordance with CMS IOM Publication 100-4, Chapter 5, Section 20.3Adobe Portable Format document: "Providers report the code for the time actually spent in the delivery of the modality requiring constant attendance and therapy services. Pre- and Post-delivery services are not to be counted in determining the treatment service time. In other words, the time counted as "intra-service care" begins when the therapist or physician is directly working with the patient to delivery treatment services. The patient should already be in the treatment area and prepared to begin treatment."

   So the reporting of therapy time, should be for time spent in direct delivery of therapy services and not including the time any pre- or post-delivery minutes.

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5. Is functional electrical stimulation (Vital Stim) covered for the treatment of dysphagia?
   Review of current literature does not support the efficacy of electrical stimulation for dysphagia. Therefore, electrical stimulation is not a covered modality for the treatment of dysphagia.

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6. Is an evaluate and treat order written by the physician acceptable for the therapist (PT, OT, SLP) to perform an evaluation and begin treatment immediately or is something else required?
   The physician must certify/approve the plan of care developed by the therapist. It is appropriate to evaluate the patient and start therapy on the day of the evaluation, while waiting for approval of the plan of care (POC), however, the certification should be on the chart within several days of initiation therapy services. CMS IOM Publication 100-02, Chapter 15, Sections 220.1.3 and 220.1.1Adobe Portable Format document

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7. When is it appropriate to bill a re-evaluation verses an initial evaluation? For example, a patient is receiving physical therapy due to a total knee replacement and during this time period he falls and fractures his wrist. The patient now needs therapy on his wrist in addition to the knee therapy.
   If the patient is receiving therapy for any given condition, and he/she has a significant change that warrants an evaluation of a second rehab need, then a re-evaluation would be appropriate and billed to Medicare. (HCPCS 97002) CMS IOM Publication 100-02, Chapter 15, Section 220.1.3Adobe Portable Format document

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8. When performing outpatient physical therapy, occupational therapy, or speech-language pathology services, is the therapist required to perform and bill a re-evaluation every 30 days for a patient who requires therapy services longer than 30 days?
   No. A re-evaluation is not a routine, recurring service but is focused on evaluation of progress toward current goals, making a professional judgment about continued care, modifying goals and/or treatment or terminating services. A formal re-evaluation is covered only if the documentation supports the need for further tests and measurements after the initial evaluation. Indications for a re-evaluation include new clinical findings, a significant change in the patient's condition, or failure to respond to the therapeutic interventions outlined in the plan of care. Re-evaluation may also be appropriate at a planned discharge. CMS IOM Publication 100-2, Chapter 15, Sections 220 and 230Adobe Portable Format document define outpatient rehabilitation services and details coverage guidelines.

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Page Last Updated: Monday, 30-Apr-2012 13:57:17 CDT

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