Additional Documentation Request

Doing it right the first time.

BY Mary R. Daulong, PT, CHC, CHP

There are many reasons payers request additional documentation, and it is critical that providers understand the importance of an orderly and timely response. An Additional Documentation Request (ADR) is typically a result of a payer’s probe or edit, which may be specific to a provider, a service, a payment threshold, a Current Procedural Terminology (CPT) code, or International Classification of Disease, 9th Edition code (ICD-9). However, an ADR from the Comprehensive Error Rate Testing Contractor (CERT) is based solely on a random sample. Regardless of the reason for the ADR, providers must take a request seriously and establish it as a high priority.

You mitigate your risk of not responding to an ADR if Medicare correspondence is separated from regular mail and is promptly given to the practice owner or his/her designee. The correspondence should be carefully reviewed noting the response/receipt timeframe as well as the information requested. Any and all communication with the auditor regarding the ADR should be documented and dated for future reference, if necessary. Swift action should be taken in response to the ADR starting with a thorough review of the record(s) requested.

While a record should never be altered after a record request is received, a provider may add documents that have not been filed or scanned prior to submitting the records for review. If a record is not legible, it along with an identical transcription of the record, may be submitted. Special attention must be made to identify the transcription as a post-ADR entry highlighting the transcription date.

Additional Documentation Request letters are usually sent in hardcopy through the U.S. Postal Service. The date of the letter marks the beginning of the response timeframe (exception: CERT ADR which is the date of ADR receipt), and the documentation receipt date will be based on the date stamped in the contractor’s mailroom. If a provider utilizes the Medicare esMD electronic system, the receipt date is the transmission date via the Enterprise File Transfer (EFT) system.

Medicare contractors are required to be clear in their ADR letters about what documentation submission methods they will accept from a provider or Health Information Handler (HIH). The Medicare Administrative Contractor (MAC), the CERT contractor, and Recovery Auditor must, according to Centers for Medicare and Medicaid Services (CMS), accept documents via paper, fax, CD/DVD, and electronic submission (via esMD). Medicare has the following expectations of contractors requesting additional documentation:

• Paper Documents. The MACs, CERT contractors, and Recovery Auditors are encouraged to state in the ADR that paper medical documentation can be mailed by any means including U.S. Postal Service, Federal Express (FedEx), United Parcel Service (UPS), or certified mail. To facilitate delivery of documentation, MACs, CERT contractors, and Recovery Auditors are expected to provide a physical mailing address rather than a Post Office Box address.
• Faxed Documents. If the MAC, CERT contractor, or Recovery Auditor has the capability to offer fax confirmation, they are encouraged to send such confirmations with every successfully received fax.
• CD/DVD Documents. The MACs and CERT contractors must state, in the ADR, that imaged documentation files on CD/DVD may be mailed by any means and the Recovery Auditor ADRs must provide a website link or phone number that provides information regarding the requirements for submitting imaged documentation on CD or DVD.
• Electronically Submitted Documents (esMD). Electronic submission of documentation allows providers/HIHs to submit documentation via a secure electronic gateway. CMS’s website link, www.cms.gov/esMD, has submission instructions.

The table below is a summary of action timeframes for providers as well as contractors:

While the Additional Documentation Request process has many rules, “getting it right the first time” can be achieved with attention to detail and a timely response. Remember, it is best to secure a consultant prior to ADR submission if there are doubts and/or uncertainties about the process.

Mary R. Daulong, PT , CHC, CHP, is a PPS member and the owner of Business & Clinical Management Services, Inc., a consulting firm specializing in outpatient therapy compliance, including documentation, coding and billing, enrollment and credentialing, and Health Insurance Portability and Accountability Act and Occupational Safety and Health Administration regulation education. She is also the author of both The Private Practice Compliance Manual and The Third-Party Biller Compliance Manual. She can be reached at daulongm@earthlink.net.