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June 20, 2012

Inpatient Service Specific Complex Review of Short Stays Diagnosis Related Group (DRG) for Nutritional Metabolic (DRG Codes 640 and 641)

The J15 Part A Medical Review department will perform a service specific complex review on inpatient services for short stays related to Nutritional Metabolic (DRG Codes 640 and 641). A Service Specific Probe Edit was conducted. There were 95 claims reviewed in Ohio with 34 denied. The total charges reviewed were $413,276.71 and the total denied charges were $145,675.39. This resulted in a charge denial rate of 35.2 percent. There were 88 claims reviewed in Kentucky with 43 denied. The total charges reviewed were $325,445.59 and the total denied charges were $150,710.25. This resulted in a charge denial rate of 46.3 percent. Based on the high charge denial rates and total denied charges this edit will progress to Complex Service Specific in both Kentucky and Ohio. 

The top three denial reasons identified were denial codes 5J504, 56900 and 5J503.

Denial Code 5J504 – (KY – 35.2 percent; OH – 34.5 percent)

  • Reason for Denial
    • The documentation submitted for review did not support the medical necessity of the services provided
  • How to Avoid a Denial
    • Documentation and tips that may be helpful to avoid future denials for this reason may include:
      • Submit documentation to support that all services were medically necessary on an inpatient basis instead of a less intensive setting
      • Documentation should include all clinical information for the dates of service billed such as physician progress notes; physical examinations; assessments; diagnostic tests and laboratory test results; history and physical; nurse’s notes; consultations; surgical procedures; orders and discharge summary; and any other documentation to support the inpatient admission
      • Include documentation of services, medication and medical interventions performed in the emergency department
      •  For elective surgical procedures, include documentation to support the necessity of the procedure including pre-surgical interventions and outcomes
  • For more information, refer to:
    • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 6, Section 6.5
    • CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 1, Sections 1 and 10
    • CMS Medicare Learning Network (MLN) Matters article Number SE1037-Guidance on Hospital Inpatient Admission DecisionsExternal PDF.

Denial Code 56900 – (KY – 6.5 percent)

  • 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 Avoid a Denial
    • Monitor your claim status on the Direct Data Entry (DDE) system. If the claim is in status/location SB6001, the claim has been selected for review and records must be submitted. Note-Records may be requested by the Medical Review department, the Claims department or the Zone Program Integrity Contractors (ZPIC). Ensure the records are submitted to the appropriate entity.
    • Alert your mail staff to be aware of any mail you receive from CGS
    • Be aware of the need to submit medical records within 30 days of the date on the Additional Documentation Request (ADR) in the upper left corner
    • 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 responding to multiple ADR’s, 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 can not accept them
    • Return the medical records to the address indicated in the ADR. Be sure to include the appropriate mail code.

Denial Code 5J503 – (KY – 4.6 percent; OH – 0.7 percent

  • Reason for Denial
    • The documentation submitted for review did not include a physician’s order to admit the patient. Please review medical records prior to billing to assure the level of care billed is consistent with the level of care ordered. Services that are not ordered by the physician are not reasonable and necessary.
  • How to Avoid a Denial
    • Physician’s order to admit to inpatient services should be clearly identified in the medical records. This order may be located within the history and physical, progress note, emergency room report and/or verbal order signed and dated by the physician.
    • The signature must be legible and should include the practitioner’s first and last name. Also include applicable credentials such as M.D., P.A. or D.O.
    • Electronic signatures are acceptable
    • Orders for inpatient admission written by a non-physician practitioner must be co-signed by the attending physician

For provider outreach and education opportunities please visit:

Providers who receive an ADR must submit the requested medical record information within 30 days to:

J15 Part A Medical Review
Mail Code: AG-735
P.O. Box 100140
Columbia, SC 29202-3140

Please mail the medical records to the following address if you are using overnight service:

J15 Part A Medical Review
Mail Code: AG-735
2300 Springdale Drive, Building One
Camden, SC 29020

This information can also be faxed to (803) 462-2596. Use the ADR letter as a cover sheet.

Providers should ensure the accuracy of their billing and send the following documentation when responding to the ADRs:

  • Physician’s orders for the admission and all services billed
  • Itemized list of all charges
  • Hospital admission assessment and hospital discharge summary
  • Hospital history and physical
  • Physician progress notes
  • Consultation reports
  • Plan of care
  • Diagnostic test results/reports, including imaging reports
  • Clinical/therapy notes
  • Please submit all documentation to support the medical necessity of services billed and the DRG code billed
  • 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 is authenticated by the author. The method used shall be a hand written or electronic signature. Stamp signatures are not acceptable. Patient identification, date of service and provider of the service should be clearly identified on the submitted documentation.

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

Questions regarding the short stay inpatient reviews can be directed to the Medical Review department at (803) 763-4999.

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