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Date:
To:
From: Administrator
Nursing Home
NPI#:
RE: Post-Payment Claim Review
Patient’s name
HIC #:
Dates of Service:
We are in receipt of the request for Post-Payment Claim Review for skilled services provided to Patient. We have gathered the requested information for the stated dates of services. In addition, please see the attached letter summarizing skilled services provided during this period.
Based upon the clinical facts in this case we feel this was a covered service according to Medicare Guidelines. Please see the attached letter and additional data submitted for your review. Please notify us in writing of your determination at:
Facility
Address
If you have further questions, please do not hesitate to contact me at ___-___-____.
Respectfully Submitted,
______________________________
Administrator
Nursing Home
Date:
To:
From: Administrator
Nursing Home
NPI#:
RE: Post-Payment Claim Review
Patient’s name
HIC #:
Dates of Service:
We are in receipt of the Post-Payment Claim Review Request for Patient’s name. We have gathered the requested information for the stated dates of services.
Our clinical team has re-reviewed the medical record for clear indicators that the daily skilled services provided during this period were medically reasonable and necessary. Our team has come to the conclusion based on an in-depth medical record review and recollections of care provided during this period by licensed professionals, that the care rendered does meet the criteria for skilled care as dictated in the Medicare Benefit Policy Manual.
Patient name is a ____ year-old male/female with a primary diagnosis of ___________________. Her/His past medical history is significant for _________________________________________.
Previously, (PLOF). Patient was referred to [speech, physical, occupational] Therapy secondary to reports that ____________________________________________________________________.
Patient name was evaluated per physician orders on [___ / ___ / ___ ]. The evaluation findings are as follows:
- _______________________________________________________________________
- _______________________________________________________________________
- _______________________________________________________________________
The PT/OT/ST Therapy treatment plan ordered by Doctor name consisted of _______________________________________________________________________________. The treatment plan dictated that OT/PT/ST provide ___ visits per week for ___ weeks to carry out the above noted treatment plan in an efficient and professional manner specific to the skills an PT/OT/ST Therapist.
On [___/ ___ / ___], Patient’s name functional status was as follows:
- _______________________________________________________________________
- _______________________________________________________________________
- _______________________________________________________________________
Upon completion of the PT/OT/ST Therapy program on [___/___/___] Patient’s functional status was clearly noted as having improved in all areas to:
- _______________________________________________________________________
- _______________________________________________________________________
- _______________________________________________________________________
As noted above, Patient made significant progress toward his/her set long term goals as a direct result of skilled OT/PT/ST. Without these skilled services, our patient was at risk for:
- _______________________________________________________________________
- _______________________________________________________________________
- _______________________________________________________________________
The following Medicare guidelines were used in our decision making process.
Medicare Benefit Policy Manual, Chapter 15
220.1 - Conditions of Coverage and Payment for Outpatient Physical Therapy, Occupational Therapy, or Speech-Language Pathology Services
Outpatient therapy services furnished to a beneficiary by a provider or supplier are payable only when furnished in accordance with certain conditions. The following conditions apply.
- Services are or were required because the individual needed therapy services
- A plan for furnishing such services has been established by a physician/NPP or by the therapist providing such services and is periodically reviewed by a physician/NPP
- Services are or were furnished while the individual is or was under the care of a physician
220.2 - Reasonable and Necessary Outpatient Rehabilitation Therapy Services
To be covered, services must be skilled therapy services as described in this chapter and be rendered under the conditions specified. Services provided by professionals or personnel who do not meet the qualification standards, and services by qualified people that are not appropriate to the setting or conditions are unskilled services. A service is not considered a skilled therapy service merely because it is furnished by a therapist or by a therapist/therapy assistant under the direct or general supervision, as applicable, of a therapist. If a service can be self-administered or safely and effectively furnished by an unskilled person, without the direct or general supervision, as applicable, of a therapist, the service cannot be regarded as a skilled therapy service even though a therapist actually furnishes the service. Similarly, the unavailability of a competent person to provide a non-skilled service, notwithstanding the importance of the service to the patient, does not make it a skilled service when a therapist furnishes the service.
Skilled therapy services may be necessary to improve a patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration of the patient’s condition.
The services shall be of such a level of complexity and sophistication or the condition of the patient shall be such that the services required can be safely and effectively performed only by a therapist, or in the case of physical therapy and occupational therapy by or under the supervision of a therapist. Services that do not require the performance or supervision of a therapist are not skilled and are not considered reasonable or necessary therapy services, even if they are performed or supervised by a qualified professional. Medicare coverage does not turn on the presence or absence of a beneficiary’s potential for improvement from the therapy, but rather on the beneficiary’s need for skilled care.
- While a beneficiary’s particular medical condition is a valid factor in deciding if skilled therapy services are needed, a beneficiary’s diagnosis or prognosis cannot be the sole factor in deciding that a service is or is not skilled. The key issue is whether the skills of a therapist are needed to treat the illness or injury, or whether the services can be carried out by nonskilled personnel.
- The amount, frequency, and duration of the services must be reasonable under accepted standards of practice.
- Rehabilitative Therapy: Rehabilitative therapy may be needed, and improvement in a patient’s condition may occur, even when a chronic, progressive, degenerative, or terminal condition exists. For example, a terminally ill patient may begin to exhibit self-care, mobility, and/or safety dependence requiring skilled therapy services. The fact that full or partial recovery is not possible does not necessarily mean that skilled therapy is not needed to improve the patient’s condition or to maximize his/her functional abilities. The deciding factors are always whether the services are considered reasonable, effective treatments for the patient’s condition and require the skills of a therapist, or whether they can be safely and effectively carried out by nonskilled personnel.
- Maintenance Programs: Skilled therapy services that do not meet the criteria for rehabilitative therapy may be covered in certain circumstances as maintenance therapy under a maintenance program. The goals of a maintenance program would be, for example, to maintain functional status or to prevent or slow further deterioration in function.
Coverage for skilled therapy services related to a reasonable and necessary maintenance program is available in the following circumstances:
- Establishment or design of maintenance programs. If the specialized skill, knowledge and judgment of a qualified therapist are required to establish or design a maintenance program to maintain the patient’s current condition or to prevent or slow further deterioration, the establishment or design of a maintenance program by a qualified therapist is covered. If skilled therapy services by a qualified therapist are needed to instruct the patient or appropriate caregiver regarding the maintenance program, such instruction is covered. If skilled therapy services are needed for periodic reevaluations or reassessments of the maintenance program, such periodic reevaluations or reassessments are covered.
- Delivery of maintenance programs. Once a maintenance program is established, coverage of therapy services to carry out a maintenance program turns on the beneficiary’s need for skilled care. A maintenance program can generally be performed by the beneficiary alone or with the assistance of a family member, caregiver or unskilled personnel. In such situations, coverage is not provided. However, skilled therapy services are covered when an individualized assessment of the patient’s clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist are necessary for the performance of safe and effective services in a maintenance program. Such skilled care is necessary for the performance of a safe and effective maintenance program only when (a) the therapy procedures required to maintain the patient’s current function or to prevent or slow further deterioration are of such complexity and sophistication that the skills of a qualified therapist are required to furnish the therapy procedure or (b) the particular patient’s special medical complications require the skills of a qualified therapist to furnish a therapy service required to maintain the patient’s current function or to prevent or slow further deterioration, even if the skills of a therapist are not ordinarily needed to perform such therapy procedures. Unlike coverage for rehabilitation therapy, coverage of therapy services to carry out a maintenance program does not depend on the presence or absence of the patient’s potential for improvement from the therapy.
The deciding factors are always whether the services are considered reasonable, effective treatments for the patient’s condition and require the skills of a therapist, or whether they can be safely and effectively carried out by nonskilled personnel or caregivers.
Please see the enclosed Nursing and Therapy documentation for the period in question. Based on the supportive documentation in the medical record, which is summarized above, it is our position that the therapy services provided were medically reasonable and necessary and provided within Medicare guidelines for this setting.
Please notify us in writing of your determination to:
Facility
Address
Respectfully Submitted,
______________________________
Administrator
Nursing Home