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Part A Medical Review Activity Log

Edit Code Description Review Type Status Documentation Requirements Checklist
5PE16 Outpatient pulmonary rehabilitation services (HCPCS codes 94625 & 94626) Targeted Probe and Educate (TPE) prepayment review Active Pulmonary Rehab ADR Checklist
5PE18 Inpatient psychiatric admissions (DRG 885: Psychoses) TPE prepayment review Active Inpatient Psychiatric Admissions (DRG 885: Psychoses) ADR Checklist
5PE28 Kidney and UTI with & without MCC (DRGs 689 & 690) TPE prepayment review Active Kidney and UTI with & without MCC (DRGs 689 & 690) ADR Checklist
5PE29 Heart Failure and Shock with MCC (DRG 291) TPE prepayment review Active Heart Failure and Shock with MCC (DRG 291) ADR Checklist
5PE30 Inpatient hospital short stay patient status reviews TPE prepayment review Pending Inpatient Hospital Short Stay Patient Status Reviews ADR Checklist
5PE40 Inpatient Rehabilitation Facility (IRF) TPE prepayment review Active IRF ADR Checklist
5PE41 Skilled Nursing Facility (SNF) Patient-Driven Payment Model (PDPM) 5-claim review Probe and educate prepayment review Completed PDPM ADR Checklist
5PE45 SNF PDPM (TOB 21X and revenue code 0022) TPE prepayment review Active PDPM ADR Checklist
5PE47 Outpatient therapy services (revenue codes 042X, 043X & 044X with modifier KX) TPE prepayment review Active Outpatient Therapy ADR Checklist
5PE48 Outpatient therapy services (revenue codes 042X, 043X & 044X with modifier KX) TPE prepayment review Active Outpatient Therapy ADR Checklist
5TC3R Services related to non-covered services/Category III CPT code utilization Prepayment review Active Non-covered Services/Category III CPT Code Utilization ADR Checklist

Updated: 10.08.2025

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