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August 16, 2013

Resource Utilization Group (RUG) Code RUB10: Probe Medical Review Results

The J15 Part A Medical Review department performed a service-specific probe review on Resource Utilization Group Code (RUG) RUB10 in Kentucky from March through May 2013. Based on a 28.8 percent error rate and the percentage of medical necessity denials, this edit will be advanced to a complex edit review.

Kentucky Service-Specific Probe Edit Results: RUG Code RUB10
  Charges Claims
Reviewed $735,141.38 97
Denied $211,416.52 56
Charge Denial Rate 28.8%  

The top denial reasons associated with this review are:

Denial Code 5D504/5H504 - Need for Service/Item Not Medically Reasonable and Necessary (60.73 percent of dollars denied)

Denial Code 5DOWN/MRDWN - Medical Review Downcode (33.89 percent of dollars denied)

  • Reason for denial:
    • The services billed were paid at a lower payment level
      • Documentation submitted for review should support the data on the MDS, paint a clear picture of the beneficiary's medical condition, and meet coverage criteria
      • Based on medical review, the documentation submitted for review did not meet the criteria for the RUG code(s) billed. As a result, reimbursement has been adjusted to a lower payment level.
  • How to prevent denials:
    • To avoid medical review downcoding of billed RUG codes, submit all documentation to support the RUG code(s) billed
    • The MDS assessment that established the RUG code billed must be supported by the clinical documentation. If any portion of the documentation to support the RUG code billed is not submitted, a down code may result.
    • When therapy RUG codes are billed, the following documentation must be submitted for review:
      • Orders for therapy services signed and dated by the physician
      • A written therapy plan of treatment established by the physician after consultation with the therapist
      • The actual minutes of therapy rendered as documented on a log/grid or in the clinical documentation to support the minutes recorded on the MDS
      • Progress notes and any other documentation to establish the medical necessity of the services rendered
  • For more information, refer to:

Denial Code 56900 - Requested Records Not Submitted (5.37 percent of dollars denied)

  • Reason for denial:
    • The medical records were not received in response to an ADR in the required time frame. Therefore, we were unable to determine medical necessity.
  • How to prevent denials:
    • Monitor your claim status on Direct Data Entry (DDE). If the claim is in status/location SB6001, the claim has been selected for review and records must be submitted. Please note: CGS may request records through our Medical Review or Claims departments, and other contractors such as the Unified Program Integrity Contractor (UPIC) may also request records. Ensure the records are submitted to the appropriate entity.
    • Alert your mail room staff to be aware of any mail you receive from CGS
    • Gather all information and submit at one time
    • Submit medical records as soon as the ADR is received
    • Attach a copy of the ADR to each individual claim
    • If you are responding to multiple ADRs, separate each response and attach a copy of the ADR to each individual set of medical records. Ensure each set of medical records is bound securely so the submitted documentation is not detached or lost.
    • Do not mail packages COD; we cannot accept them
    • Return the medical records to the address indicated in the ADR. Be sure to include the appropriate mail code.

What to Send
If you receive an ADR from CGS, submit the requested medical record information within 30 days. Before you send the requested records, we suggest you double-check the accuracy of your submitted claim.

Send the following documentation when responding to the ADRs, along with other supporting documentation. Please note: the documentation you submit in response to this request should comply with these requirements.

  • Physician's orders for the admission and all services billed
  • Itemized list of all charges
  • Plan of Care
  • Diagnostic test results/reports, including imaging reports
  • Clinical/therapy notes
  • Physician certification of the need for skilled daily post-hospital care in a skilled nursing facility
  • All documentation to support the medical necessity of services billed and the RUG code(s) submitted
  • A signature log or an attestation statement, if you question the legibility of your signature Medicare requires that medical records entries for services provided/ordered be authenticated by the author. The signature may be hand-written or electronic; stamp signatures are not acceptable. Patient identification, date of service, and provider of the service should be clearly identified on the submitted documentation.

Options for Submitting Records

  • You may submit medical records compact discs (CDs) or digital video discs (DVDs) to CGS. You must use the correct file format of tagged image file format (tiff), which may be saved to your CD/DVD.
  • You may also submit records via fax to: (803) 462-2596. Use the ADR letter as a cover sheet.
  • If you choose to respond by mail, send the requested records to the address indicated in the ADR letter.

Completed review results will be posted on the CGS website. Individual providers with significant denials will be contacted for one-on-one education.

If you have questions regarding this review, please contact the Medical Review department at (803) 763-4999.

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