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Sample Medicare Social Work Progress Notes

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					   PRN

           Professional Review Network, Inc.
      A Utilization Review and Medicare / Medical Claims Billing Company
        Keeping you informed..........                   September 2002


                                   In This Issue:

         Preparing for a Medicare Audit – tips for Providers
     Who is “DAVE”? – Data Assessment and Verification Project
   Advanced Beneficiary Notices (ABN) – Definition and Requirement


                         Preparing for a Medicare Audit
Experiencing a Medicare Audit can be an intimidating process. An essential element to
successfully surviving a Medicare Audit is preparation. KNOW WHICH
DEPARTMENT OR STAFF MEMBER HAS RESPONSIBILILTY FOR A
PARTICULAR FUNCTION AND WHERE RELATED DOCUMENTS ARE
LOCATED. A sample Medicare Document Locator Form has been included to compile
information to expedite locating forms and documents within the facility. This is
particularly important when department heads and staff members are out of the facility,
whether at educational functions or on vacation (please see attached).


Typical formats include requests from auditors for documentation to prove that all
aspects of administration of the Medicare Program are in place. These may include, but
not be limited to, the:

   1) Admission Procedure
       Medicare eligibility - copies of Medicare Card reflecting correct spelling of
        name, effective dates for Medicare Part A and Medicare Part B
       Statement to permit payment to provider - this may be a separate form or the
        language may be incorporated into the admission agreement. The “statement
        to permit payer” is required at time of initial admission AND each re-
        admission.
       Medicare Secondary Payor Form (MSP) - required on admission and each
        readmission; note the MSP Form specifically identifies “dates of service from
        and through”. There is a ten (10) year retention requirement regarding this
        document.




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       Admission Non-coverage Notification – applicable for all resident with a
        Medicare Part A number that do not meet the medical eligibility requirements
        for Part A eligibility.
      Admit to a Non-certified Bed Letter; not applicable for dual certified facilities
2)   Medicare Certification and Re-certification Procedures
      Completed, signed, and dated forms for Part A
      Completed, signed, and dated forms for Part B
      Plans of Treatment for Part A & B Rehabilitation Services
3)   Continued Stay Coverage Decisions
      Documentation of verbal notification of non-coverage; typically by telephone
        if written notification is mailed vs. hand delivered; e.g. Social Service
        documents responsible party notified, time and date of call, message
        concerning non-coverage, and last covered day (LCD) of coverage. The
        facility representative would also sign and date this notation.
      Written notification of non-coverage - Continued Stay Denial Letter (CSD)
        letter with corresponding evidence of timely notification, i.e., responsible
        party dates and signs on-site or facility retains copy of certified receipt of
        delivery notice
4)   Medical Records Verifying that Services were Reasonable, Rendered and
     Medically Necessary
      Physician’s orders, Resident H&P, Physician progress notes
      Nursing notes and all other aspects of the resident’s medical relating to the
        delivery of services for e.g. MARs and Treatment Records.
      Rehabilitation Records (evaluations, progress notes, Plans of POTs, calendars)
5)   Claims Billing Procedures
      UB-92s reflect ICD-9 codes for services and supplies billed
      Medical record review to verify services and supplies billed are documented
        as “rendered”
      Correct Resource Utilization Groupings (RUG) rates (medical record review
        to verify RUG rate reflects corresponding services and correct Activity of
        Daily Living (ADL) component)
      Correct Assessment Reference Dates (as compared to corresponding
        Minimum Data Set)
      Demand Bill Procedures are followed, i.e. timely submission of “family
        insist”/“demand bill” claims.
6)   Minimum Data Set
      Specific sections of the MDS support services provided
7)   Legibility of Documentation
      Some hospital and other health care providers are making a bona-fide effort to
        encourage and require legible documentation.
8)   Procedures for Advance Beneficiary Notices




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                           Advanced Beneficiary Notices
An Advanced Beneficiary Notice (ABN) is a written notice a physician or supplier gives
before furnishing services or supplies to a Medicare beneficiary when the physician or
supplier believes that Medicare will probably NOT pay. The purpose of the ABN is to
inform a Medicare beneficiary before he or she receives specified items that otherwise
might be paid for, that Medicare probably will not pay on a particular occasion.

Outside vendors that supply your facility with Medicare Part B services and supplies,
may discuss ABNs with you in light of Transmittal AB-02-114.

       Subject: ABNs and DMEPOS Refund Requirements- Implementation of
       Form CMS-R-131, Advance Beneficiary Notice (ABN), and of Limits on
       Beneficiary Liability of Medical Equipment and Supplies, effective
       October 1, 2002 (please see attached Forms CMS-R-131G&L, for services
       and supplies and laboratory respectively)

Outside vendors may be requesting that you have ABNs signed for all residents (blanket
or generic ABN). Please be aware that there is a “Routine Notices Prohibition” clause
that specifically states that this is not an acceptable practice and will not protect the
physician or supplier from liability. ABNs should NOT be given when the physician or
supplier expects Medicare to pay.

ABNs should be given only when Medicare is expected to deny payment (entirely or in
part) for the item or service because it is “not reasonable and necessary” under Medicare
program standards.

ABNs are NOT required for items and services that are statutorily excluded, such as:
          Personal comfort items
          Routine eye care
          Hearing aids and hearing examinations
          Routine foot care
          Dental care
          Most outpatient prescription drugs

In summary, facilities, physicians and suppliers that supply services and items under the
Medicare Part B program for services that are reasonable and necessary, will find they
will need to issue an ABN only on a rare occasion and not as a matter of standard
practice. It is NOT to be used by a physician or supplier for a service that is expected to
be paid by Medicare, as an avenue to pursue reimbursement from a Medicare beneficiary
when a claim has been rejected or denied. The normal protocol for reconsideration and
appeal of Part B claims should be followed. To refer your vendors to the Transmittal in
its entirety, it can be found at www.hcfa.gov/publicforms/transmit/AB02114.pdf. This is
a 42-page document. If you want to retrieve the forms only for your Medical Director or
contracted vendors, these can be found on pages 24-27 and are available in English and
Spanish; the English versions have been included with this newsletter.


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                                          WHO is DAVE?
As mentioned in our June newsletter, the Center for Medicare and Medicaid Services
(CMS) has contracted with private companies to provide for Medicare Medical Review,
Fraud Investigation, Cost Report Audit and other program integrity efforts. Some
facilities have experienced requests for medical records from “DynCorp” and so far these
reviews have confirmed that the medical records have been in good order!

A project that you will be hearing about in the near future is called “DAVE”. “DAVE” is
the acronym that is applicable to the Data Assessment and Verification Project. The
Centers for Medicare and Medicaid Services has awarded task orders to several different
entities to help improve the accuracy of information about Medicare beneficiaries
residing in nursing homes or receiving home health care.

CMS awarded a task order to the Computer Sciences Corporation (CSC) under the
Program Safeguards contract. CSC will focus on two specific areas, i.e. the Minimum
Data Set (MDS) for long term care and the Outcome and Assessment Information Set
(OASIS) for home health.

DAVE’s goal is to detect coding errors through onsite and offsite audits of MDS data.
Please keep in mind this effort is underway to improve MDS accuracy and to address
provider education needs.

During the test, CSC will work closely with fiscal intermediaries, state agencies, and
CMS regional offices. Also working with DAVE will be information technology experts,
a panel of academics and companies that include Delmarva Foundation (MD), ViPS
(MD), The Lewin Group (VA), and the Joint Commission on Accreditation of Healthcare
Organizations (IL).

About sixty (60) nursing homes in each state will be selected for review, with about thirty
three percent (33%) selected for onsite audits. The DAVE team will be auditing the
MDS data, associated medical records, and Medicare claims, if applicable. The project is
expected to go national in 2003.




                    LTC Division, Professional Review Network, Inc., 5126 Blazer Parkway
                    Dublin, OH 43017; 614/791-2700, 1-800-837-7764; Fax: 614/791-2707




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Description: Sample Medicare Social Work Progress Notes document sample