Revised Additional Documentation Request Limits

On November 6, 2015, the Centers for Medicare and Medicaid Services (CMS) released revised additional documentation request (ADR) limits for non-private practice settings. This would include skilled nursing facilities, home health agencies, rehabilitation agencies, comprehensive outpatient rehabilitation facilities and hospitals. This would apply to both Part A and Part B services and Part B services would include outpatient therapy.

The annual ADR Limit will be one-half of one percent (0.5%) of the provider’s total number of paid Medicare claims from the previous year. ADR letters are sent on a 45-day cycle. The annual ADR Limit will be divided by eight to establish the ADR cycle limit, which is the maximum number of claims that can be included in a single 45-day period. Although the Recovery Auditors may go more than 45 days between record requests, in no case shall they make requests more frequently than every 45 days.

For example, Provider A was paid for 47,476 Medicare claims in 2014. The provider’s ADR limit would be 47,441 x 0.005, which is 237.20. The ADR cycle limit would be 237.20/ 8 = 29.65 and would be rounded to 30 additional documentation requests per 45 days.

For example, Provider B was paid for 263,127 Medicare claims in 2014. The provider’s ADR limit would be 263,127 x 0.005, which is 1315.64. The ADR cycle limit would be 1315.64/ 8 = 164.46 and would be rounded to 164 additional documentation requests per 45 days.

To see the revised guidelines as well as the ADR guidelines for private practices, click