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September 10, 2014

Removal of Gallbladder (CPT Code 47562):  Probe Medical Review, Kentucky and Ohio

J15 Part A Medical Review will implement a service-specific probe review on Part A outpatient claims related to the Removal of Gallbladder.  The probe edit for bill type 13X will be implemented in Kentucky and Ohio.

What to Send
If you receive an Additional Documentation Request (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. This may require you to contact the admitting physician and obtain signed progress notes, results of prior testing, etc.

  • Beneficiary name and date of service on all documentation
  • Itemized list of all charges
  • Physician’s orders for the procedure and all services billed
  • Abbreviation key (if applicable)
  • Diagnostic test results/reports, including imaging reports
  • Ensure that documentation submitted describes the beneficiary’s clinical circumstances and relevant history which supports medical necessity of services billed and DRG code(s) submitted
  • Initial history and physical examination or diagnosis related to the treatment signed by physician/provider
  • Documentation of conservative therapies that were tried and failed
  • Documentation of pre- and post-procedure evaluation of beneficiary’s response to the procedure
  • Ensure that all submitted documentation is legible and complete (including signature(s))
  • If you question the legibility of your signature, you may submit a signature log or an attestation statement in your ADR response.  Medicare requires that medical record entries for services provided/ordered be authenticated by the author; the method used shall be a hand written or an electronic signature.  Stamped signatures are not acceptable.  Patient identification, date of service, and provider of the service should be clearly identified on the submitted documentation.  The documentation you submit in response to this request should comply with these requirements.  If the signature requirements are not met, the reviewer will conduct the review without considering the documentation with the missing or illegible signature.  This could lead the reviewer to determine that the medical necessity for the service billed has not been substantiated.

Options for Submitting Records

  • You may submit medical records compact disks (CDs) or digital video disks (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.
  • Do not mail packages COD.  We cannot accept them.

Completed review results will be posted at http://cgsmedicare.com/.   Individual providers with significant denials will be contacted for one-on-one education.

If you have any questions regarding this review please contact the J15 Part A Provider Contact Center at 866.590.6703.

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