Medicare Home DME MAC Jurisdiction C Home Health & Hospice Kentucky Part B Ohio Part B Kentucky & Ohio Part A
Skip Navigation

Send this page to a colleague

August 9, 2012 - Revised: 10.02.13

Complex Medical Review of Syncope and Collapse Diagnosis Related Group Diagnosis Related Group (DRG) 312

The J15 Part A Medical Review department will perform a service-specific inpatient complex review on syncope and collapse. A service specific probe edit was conducted in Ohio for syncope and collapse. There were 111 claims reviewed, with 93 claims denied. There were $403,068.84 charges reviewed, with $321,901.46 charges denied. This resulted in a charge denial rate of 79.9 percent. Based on this high charge denial rate and total denied charges, this edit will progress to complex in Ohio. The top four denial reasons identified were:

Denial Code 5J504 (73.2 percent)

Denial Code 5J503 (3.7 percent)

Denial Code 56900 (2.7 percent)

5CHGE - DRG Upcode/Downcode (0.1 percent)

Providers who receive an Additional Documentation Request (ADR) must submit the requested medical record information within 30 days to:

J15 Part A Medical Review
Mail Code: AG-735
P.O. Box 20021
Nashville, TN 37202

Please mail the medical records to the following address if you are using overnight service:

J15 Part A Medical Review
Mail Code: AG-735
Two Vantage Way
Nashville, TN 37228

Or fax to (803) 462-2596 (Use the ADR letter as a cover sheet).

Providers should ensure the accuracy of their billing and send the following documentation when responding to the ADRs:

Completed review results will be posted at Individual providers with significant denials will be contacted for one-on-one education. Questions regarding this review may be directed to the Medical Review department at (803) 763-4999.

An ISO 9001:2008 certified company

CGS Home | Site Maps | About Us | Disclaimer | Web Site Feedback | Contact Us

Centers for Medicare & Medicaid Services