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Outpatient Therapy REV Codes ADR Checklist

CGS recommends providers organize the medical documentation in the order indicated below. This will assist CGS in reviewing your documentation more efficiently and will expedite the review process. Please ensure the documentation is submitted within 45 days of the Additional Documentation Request (ADR). If the documentation has not been received, the claim will automatically deny on the 46th day for non-receipt of documentation.

Providers should submit all documentation that is pertinent to support the medical necessity of services for the billing period being reviewed. Ensure services billed are coded accurately for the service provided and the documentation supports those services. This may include documentation that is prior to the review period. Please note that the most common reason for overturned appeals is due to providers submitting new documentation upon the appeal that was omitted with the initial submission of medical records.

*Please include the beneficiary name and date of service on all documentation and include an abbreviation key (if applicable). Documentation must be legible and complete (including signature(s) and date(s)). If you question the legibility of your signature, you may submit a signature log or an attestation statement.

The Checklist below is intended to be utilized by providers as a reference when responding to ADRs to ensure each claim meets the policy requirements prior to the ADR submission. Please submit all documentation as required in the LCD or NCD, if applicable, and in accordance with the Medicare Benefit Policy Manual. It is the responsibility of the provider to submit complete and accurate documentation per the regulatory guidelines for each claim. Ensure the documentation submitted belongs solely to the intended beneficiary and documentation of another beneficiary is not present within any aspect of the medical record.

Please submit a copy of the ADR letter and enclosed cover sheet with each appropriate DCN to separate applicable documentation for review. Please ensure you include a designated point of contact (name, email, telephone number) with all records submitted in response to each ADR. CGS may contact this individual for an easily curable error identified during the review process in order to prevent a claim denial for missing documentation.

Click on the table below for a printable version.

checklist

Helpful Links:

How to Prevent Common Denials:

Ensure Documentation includes:

  • Initial therapy evaluation (start of care) and any re-evaluations (if applicable) to cover the dates of service (DOS) billed. Must be signed and dated by the licensed therapist.
  • Plan of Care (POC). This is usually included within the initial evaluation and must include diagnoses, long-term goals, type, amount, frequency, and duration of services. Must be signed by the licensed therapist and the ordering physician/non-physician practitioner (NPP) (i.e. PA, APRN). If there is an update to the POC, it must be properly signed and dated by the therapist and ordering physician/NPP.
  • Certification and recertification (if applicable) for the plan of care. If the physician’s signature is not signed electronically, the physician’s NAME and Credentials must be PRINTED on the certification. If the signature is illegible, the claim will be denied.
    • Exceptions for delayed certifications and recertification requirements shall be deemed as satisfied when a physician/NPP approves a certification accompanied by a reason for the delay. In addition, certifications are also acceptable without justification for 30 days after they are due, i.e. within 60 days of the initial treatment.
  • Daily therapy/treatment notes with minutes documented for each timed code for the DOS billed. Must be signed and dated by the licensed therapist.
  • Progress notes (every 10th treatment date). If a progress note is not completed during the DOS billed, please include the progress note completed prior to the DOS billed. Must be signed and dated by the licensed therapist.
  • Orders and required documentation must be signed and dated. Claims will be denied for illegible signatures. If the physician’s signature is not signed electronically, the physician’s NAME and Credentials must be PRINTED on the order.
  • Physician office/progress notes indicating reason patient requires therapy (if available).
  • Therapy Cap Exceptions. (most conditions would not ordinarily result in services exceeding this cap).
    • Include the KX modifier to appropriate claim lines to indicate the clinician attests those services at and above the therapy caps are beneficial and medically necessary and this supportive documentation is submitted with the medical record.

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Providers may include an outline or cover letter with their documentation. This can be used by CGS Medical Review staff as an Index and prove very helpful to provide the location of key documentation that supports payment of the claim. However, the cover letter cannot be used as documentation, and the documentation must support the contents of the cover letter in order to be useful.

In addition, providers may use brackets, such as [ ] or { }, asterisks (*) or underlined text in the documentation to draw the reviewer's attention to important information. However, notations should not alter, or give the appearance of altering, the documentation. The use of a highlighter is not recommended as documentation may not be legible.

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Please contact J15AMREDUCATION@cgsadmin.com for further questions, concerns, or educational needs related to this review. Be sure to include the facility name and provider number/PTAN for the inquiry. Ensure CGS is current with provider contact information for any educational outreach opportunity.

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