What is necessary when submitting medical record documentation for an Additional Documentation Request (ADR)?
The following medical record documentation should be submitted when responding to an additional development request (ADR). • Hospital discharge summary or hospital or SNF transfer sheet • History and physical • Physician signed orders and physician progress notes • Signed and dated certification or recertification for skilled care • All nurses notes, therapy plan(s) of treatment, therapy evaulations, therapy minutes, therapy notes and progress notes from 30 days prior to the assessment reference date or since admission for each Rug III code billed and through the dates of service • Medication, treatment, and wound care records, dietician notes • Signed Medicare MDS for each of the RUG III codes billed • If this is an adjusted claim and the HIPPS was changed due to an error on a prior claim, submit documentation for the reason for the correction It is important to note that each RUG III code billed must be supported by the information within the medical record. Therefore, you will need
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