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09/26/2011 - Revised: 12.22.14

Medical Review Skilled Nursing Facility (SNF) Fact Sheet

Medical Review Department

For e-mailed messages please include provider name, provider number, phone number and contact person. For questions regarding anything other than medical review or edit status, such as billing or appeals information, please call the Provider Contact Center (PCC) at (866) 590-6703.

ICD-9-CM Coding

The following sources may be helpful for issues related to ICD-9-CM coding. For Centers for Medicare & Medicaid Services (CMS) computer based ICD-9-CM training, visit www.ahima.orgExternal Website. For the American Hospital Association Coding Clinic for ICD-9-CM, visit www.ahacentraloffice.orgExternal Website.

Additional Documentation Requests (ADRs)

An ADR is a request from CGS for copies of medical records for review purposes:

  • A provider has 30 days to respond and submit documentation for review
  • ADRs are mailed in a bright yellow envelope with 'ADR Request Time Sensitive' in red on the envelope
  • Submit the requested documentation to the address on the ADR using the appropriate mail code
  • It is suggested that the provider track an ADR from the time it is received/printed until the agency receives a Remittance Advice
  • Using the DDE system, the provider may monitor which claim(s) are in the ADR status/location SB6001
  • To print a hardcopy ADR from DDE, select 01 'inquiries'. Press enter and select 12 for 'Claims' at the sub-menu. Press enter. Tab to the S/LOC field and type SB6001. All claims in this S/LOC will be reflected in the 'Claim Summary Inquiry' screen.
  • Following medical review, if there is a difference on the Remittance Advice between the submitted charges and the agency's payment, the provider can access the Remarks section to determine the reason for any denials/down codes of claims. At the DDE main menu, select 02. Press Enter. Select 26 and press enter. Enter page number '04' and press enter. Medical Review remarks are located on page 04. If a review note is not available on this page, contact the Provider Contact Center for assistance.

Comprehensive Error Rate Testing (CERT)

The CERT contractor is an independent Centers for Medicare & Medicaid Services (CMS) contractor and not part of CGS. You can visit CMS' website at https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT/index.htmlExternal Website. However, CGS has provided CERT information. To access, select 'CERT' on the left side of this Web page.

The following article is listed under the General Information category:

  • The ABCs of the Comprehensive Error Rate Testing (CERT) Program and How to Respond to CERT Requests

CMS Online Manuals

Visit https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/IOM/list.aspExternal Website. Select CMS Internet Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual for coverage issues. For billing issues, select CMS IOM, Publication 100-04, Medicare Claims Processing Manual.

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