Medical Review Widespread Edits
The goal of CGS's medical review (MR) is to reduce errors by preventing the initial payment of claims that do not comply with Medicare's coverage, coding, payment and billing policies. To achieve the goal of the MR program, we conduct data analysis and evaluate other information. The goals of the data analysis program are to identify provider billing practices and services that pose the greatest risk to the Medicare program.
Providers may conduct self-audits to identify coverage and coding errors using the Office of Inspector General (OIG) Compliance Program Guidelines.
Below are the medical review edits currently in place.
Edit Number | Description |
---|---|
5091T | This edit selects hospice claims with HCPC codes Q5003 (Hospice care provided in nursing long term care facility (LTC) or non-skilled nursing facility (NF)) and Q5004 (Hospice care provided in skilled nursing facility (SNF)), for any non-oncologic diagnosis code and a length of stay greater than 180 days. |
Edit Number | Description |
---|---|
5023T | This edit selects home health claims for diagnosis 401.9 (Hypertension) and a length of stay greater than 120 days. |
5250T | This service is subject to pre-claim review and no unique tracking number (UTN) is present on the claim. |
5251T | Service is the same as denied service and service has no pre-claim review |
C546A | The item or service exceeds the number of allowed services within the episode period based on the pre-claim review decision. |
C547A | The date for the item or service is before or after the designated episode period or overlaps the episode period based on the pre-claim review. |
Updated: 12.16.16