Writing an Appeal Letter
Lisa Werner Bazemore, MBA, MS, CCC-SLP
Director of Consulting Services
Levels in Medicare Appeals Process
1. Additional Development
Request (ADR)
 Fiscal Intermediary determines
whether or not to pay the claim.
2. Redetermination
 FI considers their original
determination based on your
appeal.
3. Reconsideration
 The Qualified Independent
Contractor considers your
appeal.
4. Hearing
 The Administrative Law Judge
hears your appeal.
5. Review
 The Medicare Appeals
Council/Department of Appeals
Board will review the decision of
the ALJ.
 Next, the Federal District Court
will hear you case on disputed
claims.
* The Medicare Appeals Process
is the same for Medicare A and
Medicare B claims
Additional Development Request
(ADR)
Additional Development Request
 Is a written request from the FI for a medical record which will
be reviewed before payment is rendered.
 Frequently comes into the billing office or the medical records
department.
• Make sure ALL billing and medical records staff are aware of what
an ADR is and that they have to notify you (or delegate) before
sending out medical records.
 Tips:
• Documentation is time sensitive
• Note the source of the document
• Note the reason for the request if one is given
 Be aware:
• You have 120 days from the date of receipt of the notice. This is
presumed to be 5 days after the date of the notice.
Additional Development Request
(ADR)
After you have carefully reviewed the FI correspondence:
 Follow the directions from the fiscal intermediary completely.
• Once the record is copied review it again for completeness and
accuracy.
• Be sure that each page is copied front and back.
• Make a copy of the packet prior to sending it to the FI so you know
exactly what the FI had for review.
 Send the record to the FI contact as provided on the letter
using a delivery method that offers a tracking number.
RAC Exception
RAC Process
 Charts will be requested and reviewed
 Determination will be rendered and sent to the provider
 The provider has 15 days to rebut the decision of the RAC
before the RAC can request funds from the FI
 The RAC will consider the rebuttal
 If payment is denied, they will notify the FI
 Your claim is not a denial until the RAC requests funds
from the FI
 You have 120 days to appeal the decision from the date
of the remittance advice
Redetermination
The Initial Appeal
 If the FI does not believe that your documentation meets their
criteria for payment, you will receive notification that the claim
was denied.
 At this stage you will send your record back to the FI with a
cover letter stating why you believe this claim should be paid.
Reconsideration
The initial appeal was considered and denied, so now you seek
reconsideration with a Qualified Independent Contractor
 If the FI rejects your initial appeal, you can appeal the claim at
the QIC.
 This is the last stage when you can submit new evidence, so
consider what input may be available to strengthen your claim.
Letters
You can submit information that will help you make your case
for payment.
 Types of letters to include:
• Letter from the treating physician regarding the medical necessity
of the stay (ADR cover letter).
• Letter to explain the organization of the medical record being
submitted. Include for all appeals.
• Redetermination cover letter to rebut the reason for the initial
denial.
• QIC cover letter to rebut the reason for the initial denial and the
denial at the redetermination stage.
• Letter from the referring doctor to address the reason for the
referral and perceived necessity for rehab.
• Letter from the patient or family member to indicate the need and
value of the rehabilitation stay.
Preparing the Appeal –
The Appeal Letter
The Appeal Letter
 The body of the appeal letter should contain the following
information:
• Discuss the reason for the appeal
• Support the medical necessity of the claim according to the
conditions of participation
• Defend each week of care
• Explain that the admission was appropriate for your level of care
and services were reasonable and necessary
• Cite specific Medicare regulations such as the conditions of
participation in your letter where applicable
Preparing the Appeal –
M.D. Request Letter
M.D. Request Letter
 Request help from the doctors:
• Prepare a form letter to send to the treating physician to solicit help
with the appeals process.
 Explain the reason for the FIs request (probe, RAC, program
integrity)
 Let the doctor know that their opinion makes a difference and
carries weight with auditors.
 Provide a template of what to include.
 Indicate a deadline for their letter to be submitted to you so you can
include it with the appeals packet.
 Thank them profusely
 Be prepared to write the letter for them to sign.
Preparing the Appeal –
Treating Physician’s Template
Template should include
 Summary of etiologic diagnosis/reason for rehab.
 Pt. required:
• 24 hour availability of rehab MD for _______
• 24 hour availability of rehab nurse for _______
• Multidisciplinary (or interdisciplinary) team approach
• Coordinated plan of care
• Intense level of therapy services
 Pt. demonstrated:
• Significant practical improvement
• Achieved realistic goals in an appropriate time frame (LOS)
 Reason care could not be provided in a SNF
Preparing the Appeal –
M.D. Request Letter
Example of M.D. Cover Letter
 Explain reason for admission
• Ms. Example is a 67 year old female who underwent a lumbar
decompression and fusion on March 14, 2007 for spinal stenosis
and chronic back issues. Her full procedure was that of an L3
through L5 decompression and fusion from L3 to S1, as well as a
TLIF at L4-5 and L5-S1. Secondary to this surgery and her
premorbid condition, she was noted to have decreased mobility and
inability to be independent in ADLs. She had multiple comorbidities,
including requiring two liters of oxygen at night chronically, a
history of arrhythmias, history of asthma, COPD, and depression.
Preparing the Appeal –
ADR Cover Letter Example
Example of ADR Cover Letter
 Review the 8 conditions:
• She was evaluated by our preadmission team and was felt to be an
appropriate candidate for rehabilitation. The reason for this was
related to her recent surgery, long term back issues and multiple
comorbidities. It was felt that she required 24-hour availability of a
rehabilitation physician, secondary to her respiratory issues,
hypertension, history of cardiac arrhythmias and for aggressive pain
management. She also required 24-hour availability of rehabilitation
nursing to assist in pain management, monitor her respiratory and
cardiovascular status, and provide education and training in ADL
activities. Due to the complexity of her back surgery and multiple
comorbidities, it was felt that she required a multidisciplinary team
approach with a coordinated plan of care at the intense level of
therapy services that can be found in an acute inpatient
rehabilitation facility. It was not felt that this therapy could have
been provided at a lesser intense level of care.
Preparing the Appeal –
ADR Cover Letter Example
 Provide Therapy Necessity:
• Functionally, at the time of admission, she was noted to be modified
independent for eating and she remained so at discharge. Grooming
was noted to be supervision and she became modified independent
at discharge. Bathing was moderate assistance and was supervision
at discharge. Upper extremity dressing was noted to be minimum
assistance on admission, modified independent at discharge. Lower
extremity dressing was maximum assistance on admission and
supervision at discharge. Toileting was moderate assistance on
admission and minimal assistance at discharge. With respect to
bowel and bladder management, she was at a modified
independent level at admission and remained so at discharge.
Transfers from the bed to wheelchair were minimum assistance at
admission and modified independent at discharge. Toileting and tub
and shower transfers were noted to be minimum assistance at
admission and supervision on discharge. With regard to locomotion
she was noted to be maximum assistance for walking at admission
and modified independent at discharge. Stairs were noted to be
maximum assistance on admission and modified independent at
discharge.
Preparing the Appeal –
ADR Cover Letter Example
 Provide Medical Necessity:
• From a medical standpoint, she was monitored closely with respect
to her pain management. Medications were adjusted, including
adding other modalities such as Lidoderm patch and TENS trials.
She also had the addition of Neurontin to address the neuropathic
component of her pain. Overall her pain management was improved
throughout her stay. Her cardiac status was monitored. She was
maintained on her Digitek and Isoptin and blood pressures were
monitored as well. Also, she was kept on her antihypertensives
from admission. Regarding her respiratory status, she was kept on
oxygen at night. She did have frequent documented episodes of
desaturation to the mid 80’s on room air with exertion and
therefore required supplemental oxygen at discharge. Her
depression was monitored as well and she was maintained on
Effexor.
Preparing the Appeal –
ADR Cover Letter Example
 Summarize Findings:
• Overall, from a medical standpoint with the close medical
management and rehabilitation nursing, she did well in that area. It
should also be noted that she remained anemic throughout her stay
with her hemoglobin both on admission and discharge varied from
8-9 mg/dl. She was treated with iron supplementation and Epogen.
From the functional standpoint, as can be seen above, she
improved significantly throughout her rehabilitation stay in a
relatively short period of time. She was subsequently discharged to
home with her family. In my opinion, Ms. Example was treated in
the most appropriate setting for her rehabilitation needs and it is
not likely that she would have achieved such medical improvements
and stability during her rehabilitation course without the assistance
of a rehabilitation physician and a rehabilitation nurse. In addition,
without the assistance of the multidisciplinary team, I don’t believe
she would have had such excellent functional improvements during
her stay that allowed her to return back to her home setting within
a week.
Preparing the Appeal –
ADR Cover Letter Example
 Provide Additional Resources:
• Additionally, we have provided appendices for your reference for the
tabulation of therapy minutes (Appendix A) and how our medical
records are organized (Appendix B).
• Please do not hesitate to contact me if you have any questions or
need clarification.
Preparing the Appeal –
ADR Cover Letter Example
Appendix B Excerpt
 Before the tabs begin you will find the following:
• Inpatient Admission Record – contains demographic information
• IRF- PAI (Inpatient Rehabilitation Facility - Patient Assessment
Instrument)
• Coding Summary Form
• A summary for each tab is listed below
 White Tab – Admission
• Request for Treatment & Authorization
• Advance Directives Acknowledgement Form
• Pre-admission Assessment
• Referring Hospital Therapy Notes (if available)
Preparing the Appeal –
Redetermination Request
Letter
After initial determination = denial, write a redetermination
request
 The request should detail how the claim meets medical
necessity for the reasons sited for denial.
 Consider presenting proof on all 8 conditions of participation
Preparing the Appeal –
Redetermination Request
Letter Example
Reasons for Denial
 To Whom it May Concern:
 The above referenced claim was denied at determination due to the
following four (4) reasons:
• The documentation submitted did not demonstrate the intense level of
rehabilitation services were provided to the patient.
• The documentation submitted did not reflect the degree of physician
involvement, which is normally only rendered in a hospital setting.
• The documentation did not reflect the need for 24-hour availability of a
registered nurse with specialized training/experience in rehabilitation.
• The documentation submitted indicated the patient could have achieved his
improvement in a less intensive setting.
 For your review, enclosed is a complete copy of the medical records,
numbered on the lower right corner of each sheet from Page 1 to 593.
The Provider respectfully requests that all of these documents be
carefully reviewed. When the record is reviewed in its entirety
Provider’s claim is properly supported and should be paid.
Preparing the Appeal –
Redetermination Request
Letter Example
Patient Summary
 In summary, Mr. X is a 92-year old gentleman who suffered a
clinical stroke that left him with an objective left facial droop
dysarthria, dysphasia and right-sided in-coordination and was
admitted to Carolinas Rehabilitation from 11/24/06 through
12/15/06. Premorbidly the patient was in his normal state of
health independent with communication cognition, mobility
transfers and activities of daily living. His case was reviewed
by our consult physiatrist and was determined to be appropriate
for inpatient rehabilitation as this is the most appropriate
setting for his recovery from his stroke. It was also determined
that he required 24 hours availability of a rehabilitation
physician as well as a rehabilitation nurse or management in
light of his dementia, hypertension, COPD and history of alcohol
and tobacco abuse.
Preparing the Appeal –
Redetermination Request
Letter Example
Patient Summary (continued)
 Mr. X required and received a comprehensive interdisciplinary
stroke specialized rehabilitation program that included
rehabilitation patient therapy, occupational therapy, speech
therapy, medical social worker, therapeutic recreation services
and medical psychology services. A formal team conference led
by a physiatrist occurred on a twice weekly basis to insure a
program of care. Mr. X participated in an intense occupational
and physical therapy program that allowed him to achieve his
established goals in a reasonable time. Unfortunately, due to a
lack of family support for ongoing assistance, the patient
subsequently was discharged on 12-15-06 to a sub-acute
skilled nursing facility for ongoing decreased level of
supervision and care.
Preparing the Appeal –
Redetermination Request
Letter Example
Regulation Citation and Rebuttal of Denial
 Denial Rebuttal
• 1. The documentation submitted did demonstrate the intense
level of rehabilitation services were provided to the patient.
• Pursuant to Medicare Benefit Policy Manual, Chapter 1, §110.4.3,
the Provider either provided and the beneficiary received at least 15
hours of combined therapy per week or documented that the
patient had a condition which prevented such participation in
therapy. Furthermore, Medicare Benefit Policy Manual, Chapter 1,
§110.1 requires that determinations of medical necessity for IRF
services be based upon an assessment of each patient’s individual
needs and prohibits denials of payment based on “numerical
utilization screens, diagnostic screens, diagnosis or specific
treatment norms, ‘the three hour rule,’ or any other ‘rules of
thumb.’”
Preparing the Appeal –
Redetermination Request
Letter Example
• Mr. X required an intense level of therapy services as evidenced by
the pre-admission document that can be found on pages 11-17. An
intense level of services was ordered in the admission orders on
page 50-52. Mr. X participated in therapy as per the grid in
Appendix A. He received 1080 minutes in week 1 and 1260 in week
2 and 1260 in week 3. This indicates that Mr. X received more than
the required amount of therapy.
Preparing the Appeal –
Redetermination Request
Letter Example
 Denial Rebuttal (Regulation Citation and Rebuttal of Denial, continued)
• 2. There was sufficient documentation to substantiate close
medical supervision by a physician with specialized training
or experience in rehabilitation.
• Pursuant to Medicare Benefit Policy Manual, Chapter 1, §110.4.1,
the Provider demonstrated that the patient required the 24-hour
availability of a physician with special training or experience in the
field of rehabilitation as evidenced by entries in the patient’s
medical record that reflect frequent, direct and medically necessary
physician involvement in the patient’s care: i.e., at least every two
to three days during the patient’s stay.
• Mr. X required the oversight of a rehabilitation physician for
management of his functional and medical needs. His medical
complications included recent stroke, hypertension, COPD, urinary
tract infection, and sleep disturbance.
• Mr. X required frequent intervention for the following diagnoses:
 Nutritional compromise – we consulted nutrition who assisted with
ensuring Mr. X had proper nutritional intake.
Preparing the Appeal –
Redetermination Request
Letter Example
 Urinary tract infection – we diagnosed this infection on November
27th. A UTI in an elderly person can significantly impair their
cognitive and functional condition. It was important to monitor Mr.
X closely to ensure he was able to continue to participate in his
rehabilitation program.
 Hypertension – which was a contributor to his stroke, was an issue
during his rehab stay. We monitored his pressures closely and
determined an adjustment to his Norvasc dosing was required.
Once the dose was adjusted we continued to monitor to ensure the
change was effective. We also monitored the patient’s neurological
status as he was at significant risk for a second stroke.
 Sleep disturbance – we prescribed Trazodone for Mr. X’s sleep
disturbance and monitored his response. He needed to have
adequate sleep so he could participate in the full benefit of his
therapies. Additionally we monitored the amount of time he slept
with a sleep log to ensure the treatment was effective.
 In addition to managing the medical complications detailed above, I
coordinated the plan of care for nursing and therapy.
Preparing the Appeal –
Redetermination Request
Letter Example
 Denial Rebuttal
(Regulation Citation and Rebuttal of Denial, continued)
• 3. There was documentation to validate the requirement of
24-hour availability of a registered nurse with specialized
training or experience in rehabilitation.
• Pursuant to Medicare Benefit Policy Manual, Chapter 1, § 110.4.2
the facility demonstrated the patient required the 24-hour
availability of a registered nurse with specialized training or
experience in rehabilitation through the comprehensive rehab
nursing documentation found in the Nursing documentation sections
as well as in the multidisciplinary team meetings.
Preparing the Appeal –
Redetermination Request
Letter Example
• Mr. X required the 24-hour availability of a rehabilitation nurse to
treat the following:
 Skin integrity concerns due to decreased mobility, hemiparesis and
nutritional deficits treated by nursing via daily skin assessments,
application of prescribed medications and pressure ulcer prevention
techniques.
 Safety concerns due to weakness, hemiparesis, and cognitive
deficits. Interventions included frequent monitoring and assistance
with mobility.
 Nutrition and hydration issues in light of recent cerebrovascular
accident. He was treated with rehabilitation nursing education,
nutritional consult and prescribed medications
Preparing the Appeal –
Redetermination Request
Letter Example
• Knowledge deficit in the areas of nutrition, safety, medication
management, complications of diagnoses, advanced directives,
pain, patient rights and responsibilities, infection control, and self
care. Education on these items was provided during his entire stay
and evidence can be found on pages 565-567.
• Mobility and self care deficit was treated by nursing by carryover of
therapy techniques during outside of therapy. Nursing
documentation of therapy carryover can be found in the
rehabilitation nursing documentation and in the interdisciplinary FIM
document on pages 91-128.
• In ordering rehabilitation nursing at Carolina’s Rehabilitation it was
known that nursing would perform daily assessment and
intervention on fall risk, neurological checks, psychosocial status,
respiratory status, cardiovascular status, gastrointestinal status,
renal status, bowel and bladder status, mobility, wound care, pain,
safety and intake and output monitoring. Assessment and
intervention on these items can be found in the daily nursing
documentation.
Preparing the Appeal –
Redetermination Request
Letter Example
 Denial Rebuttal
(Regulation Citation and Rebuttal of Denial, continued)
• 4. The documentation submitted indicated the patient could
not have achieved his improvement in a less intensive
setting.
• Pursuant to Medicare Benefit Policy Manual, Chapter 1, § 110.4
Rehabilitative care in a hospital, rather than in a SNF or on an
outpatient basis, is reasonable and necessary for a patient who
requires a more coordinated, intensive program of multiple services
than is generally found out of a hospital. A patient probably
requires a hospital level of care if they have either one or more
conditions requiring intensive and multidisciplinary rehabilitation
care, or a medical complication in addition to their primary
condition, so that the continuing availability of a physician is
required to ensure safe and effective treatment.
Preparing the Appeal –
Redetermination Request
Letter Example
• As can be seen from a review of the medical record, Mr. X had
significant medical comorbidities prior to and during his rehab
admission that required frequent and direct interventions from the
physiatrist and rehabilitation nurse. Based on this and his
functional needs, it was appropriate to admit him into an acute
inpatient rehabilitation facility. When it became apparent his family
would not be able to care for him in the community and he no
longer needed the 24 hour availability of a rehab physician and
nurse he was discharged to a skilled nursing facility as was
appropriate.
Preparing the Appeal –
Redetermination Request
Letter Example
Regulation Citation and Additional Information
 Additional Information
• Pursuant to Medicare Benefit Policy Manual, Chapter 1, § 110.4.6
hospitalization after the pre-admission screening is covered only in
those cases where the pre-admission screening results in a
conclusion by the rehabilitation team that a significant practical
improvement can be expected in a reasonable period of time. It is
not necessary that there be an expectation of complete
independence in the activities of daily living, but there must be a
reasonable expectation of improvement that is of practical value to
the patient, measured against the patient’s condition at the start of
the rehabilitation program. Mr. X’s pre-admission assessment on
pages 11-17 indicated inpatient rehabilitation was the most
appropriate setting. In rehabilitation his progress from maximal to
moderate assistance with most functional activities and mobility
progressed to moderate to minimal assistance with most functional
activities (please see therapy evaluation on page 485-487 and
discharge summary on pages 483-484 for complete functional
results) was significant in that it lessened the burden of care to his
caregivers.
Preparing the Appeal –
Redetermination Request
Letter Example
• Pursuant to Medicare Benefit Policy Manual, Chapter 1, § 110.4.7
the most realistic rehabilitation goal for most Medicare beneficiaries
is self-care or independence in the activities of daily living; i.e., selfsufficiency in bathing, ambulation, eating, dressing, homemaking,
etc., or sufficient improvement to allow a patient to live at home
with family assistance rather than in an institution. Additionally the
Policy Manual states the aim of the patient’s treatment is to achieve
the maximum level of function possible. Review of the physical
therapy and occupational therapy evaluation on pages 485-487
shows the patient’s assessment levels as requiring physical
assistance with the majority of self care and mobility items. Page
487 of the evaluation shows the goals established as supervision for
most functional independence measure items. Achieving this level
of independence would have enabled Mr. X to return to the
community with supervision.
Preparing the Appeal –
Redetermination Request
Letter Example
Conclusion
• I do not believe that Mr. X could have received this required care at
any other setting other than an acute inpatient rehabilitation facility.
The patient, in my opinion, was most appropriately treated at an
intensive rehabilitation level of care and, in my opinion, would have
more than likely had significant medical complications and worse
functional outcome if treated at a lower level of care.
• Please also see attached Appendix A - a spreadsheet that
summarizes the amount of combined therapy the beneficiary
received and Appendix B - a guide to the structure of the medical
record.
• We respectfully request that you render a favorable decision so that
Carolinas Rehabilitation may receive Medicare payment for the
above-referenced claim. Should you need any further information
or documentation, please do not hesitate to contact me. Thank
you.
• Respectfully, Winning Doctor, MD, Carolinas Rehabilitation
Preparing the Appeal –
Supporting Letters
Consider letters from the referring M.D. and the patient
 Referring M.D.
• Send a letter from the attending rehab doctor
 Remind them of the patient and your screening process to validate
the patient’s selection
 Explain the FI’s activity in your facility and area
 Let them know how and why you are proceeding with the appeals
process
 Underscore the importance of maintaining access to care and your
facility’s mission
• Write the letter for the doctor and list why rehab was necessary
Preparing the Appeal –
Supporting Letters
 Patient
• Send them a letter at denial, assuring them they will not have to
pay
• Explain the FI’s activity in your facility and area
• Let them know how and why (because the denial was an error) you
are proceeding with the appeals process
• Underscore the importance of maintaining access to care and your
facility’s mission
• Ask them to write a letter saying why they needed inpatient rehab
• Have them send you the letter so you can use in the
Redetermination, Reconsideration, and above.
The Medical Record
Where do you find this information in your chart?
 Is that a really good question?
Physician Documentation
Purpose
 Establish medical necessity
 Clearly state why the patient needed to occupy an inpatient
rehabilitation bed
 Indicate why the patient requires an intense level of
rehabilitation services
 List problems and services that are needed
 Define why patient could not have their needs met in a skilled
nursing facility
AND
 Document information required to ensure continuity of high
quality care
Physician Documentation
What’s so special about Physical Medicine and Rehabilitation?
 Combining into one Plan of Care
• Medical treatments
• Therapy treatments
 Three levels of documentation quality
• Basic: Some documentation of therapy status and goals in the same
document as medical status
• Advanced: Documentation about therapy treatment status, plan
and goals in the same document as the medical treatment plan
• Exemplary: Links medical and therapy issues so it is clear how the
two are interrelated
Physician Documentation
Review the physician’s documentation for evidence of:
 Conditions and comorbidities addressed
 Evidence of complications that were prevented due to medical
care
 Guidance and leadership provided to the nurses and therapists
• Comments on how medical complications impacted functional
progress
• Notes on interactions with consulting physicians and changes to
medical or functional plan based on the consultation.
 Medical care rendered that would not be provided in a less
intense level of care
Team Documentation
Look for documentation of skilled services
 Consider reporting summaries of use of examples where skilled
terminology and objective measurements were in
documentation to show functional progress and improved
safety.
• Examples include:
 Assessment of performance
 Adaptation of the task or environment
 Training in the use of adaptive equipment
 Use of specialized treatment techniques
 Adjusting the treatment program as the patient's condition changes
 Providing analysis of performance and skilled feedback on
performance
Team Documentation
Look for documentation of skilled services
 Documentation that the patient was able to follow directions,
retain the skills learned, and show carryover of the learned
skills into other functional areas.
 Justification of the need to continue treatment based on
progress, treatment goals, and functional level needed at
discharge.
 Explanation of setbacks or lack of progress while supporting
that the patient retained good potential to achieve the set
goals.
Team Documentation
Team has an ongoing opportunity to document medical
necessity. Did they document?
 That services needed were of a complex nature that they
required a licensed clinician
 Services were consistent with diagnosis, need, and medical
condition
 Services were consistent with the treatment plan
 Services were reasonable and necessary
 Patient was making progress towards reasonable goals
Nursing Documentation
Items that show that rehabilitation nursing services were
necessary 24/7:
 Nursing plan addresses rehabilitation needs of the patient
 Supports medical management as laid out by physician
 Addresses education needs of the patient
 Establishes continuity of care among the team
Nursing Documentation
Showing progress:
 At least weekly, return to the established team goals.
 Note where progress has been made by stating current status
compared to prior status.
 Review previous narrative notes to determine what burden of
care was present earlier that is now resolved.
 Indicate how nursing interventions resulted in a positive
outcome.
Therapy Documentation
At least weekly, a summary of the patient’s progress should be
documented.
 Document progress toward goals
 Detail barriers to achievement of goals
 Describe changes to the plan of care as appropriate
 Describe patient’s response to treatment
 State the justification for continued stay on the rehab unit
Therapy Documentation
Common Treatment Areas
• Normalize muscle tone
• Facilitate functional movement patterns
• Improve coordination
• Improve postural control, kinesthesia, and proprioception
 Documentation
• Indicate the specific techniques rendered (e.g., NDT, PNF,
Feldenkreis)
• Explain how these techniques affect muscle tone and improve
balance, coordination, posture, proprioception, and kinesthetic
sense
• Example
 NDT and PNF techniques used to normalize hypertonic left UE and
facilitate controlled voluntary movement in functional patterns. This was
followed by PNF in bilateral reciprocal combined D1 and D2 diagonals to
achieve minimal assistance with donning and doffing a jacket.
Therapy Documentation
Common Treatment Areas
 Self-Care Dependence
• Will be noted in such areas as eating, bathing, dressing,
maintaining hygiene
• May be due to:
 Decreased strength
 Marked muscle spasticity
 Moderate to severe pain
 Contractures
 Incoordination
 Perceptual motor loss
Therapy Documentation
Common Treatment Areas
 Mobility Dependence
• Will be noted in such areas as transfer, gait deviation, stair
climbing, and wheelchair maneuvering
• May be due to:
 Decreased strength
 Marked muscle spasticity
 Moderate to severe pain
 Contractures
 Incoordination
 Perceptual motor loss
 Orthotic need
 Need for ambulatory or mobility device
Therapy Documentation
Common Treatment Areas
 Safety Dependence/Secondary Complications
• May manifest in the performance of activities of daily living or to
acquired secondary complications that could intensify medical
sequelae such as fracture nonunion, or decubiti.
• Some examples of safety dependence are high probability of
 Falling
 Swallowing difficulties
 Severe loss of pain or skin sensation
 Progressive joint contracture
 Infection requiring skilled PT intervention to protect the patient from
further complication
Appeals Tracking
What eRehabData® tracks:
How we report it:
 Type of request
 Active appeals
 Dates of correspondence
with the FI
 Closed appeals
 Dates of responses
from the FI
 Reason for denial
 Payment/denial amounts
 Total cases in appeal
at each stage
 Total dollars in dispute
at each stage
 Total dollars paid
at each stage
 Total dollars denied
at each stage
Appeals Tracking
Data Repository
 Allows you to upload medical records for storage in
eRehabData®
 Can keep records in storage for later review
 Others can access records with the proper privileges
 Assistance with appeal preparation can occur from remote
locations
Words of Wisdom
Words of Wisdom
 Appeal all claims
 Track all claims
 Adhere to time frames
• Receive information from Business/Finance Office in a timely
manner
• Respond in a timely manner with the correct documents
 Review carefully all documents from the FI
 The ADRs may come in quickly and in large numbers
• Have a system to make the process flow smoothly
• Appoint a person or two to write the initial appeals to gain
proficiency. Proficiency yields efficiency.
Thanks
Thank you to Carolinas Rehabilitation in Charlotte, NC,
for the examples provided and their willingness to share
with all of us what they perfected during their experience
with a Fiscal Intermediary Probe Audit.
Thank you to Suzanne Snyder who prepared many of these
slides for original use in the Supporting Medical Necessity
workshop sponsored by eRehabData®.
Questions?
Lisa Werner Bazemore, MBA, MS, CCC-SLP
Lbazemore@erehabdata.com
202-588-1766