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July 23, 2012

Complex Medical Review of Circulatory Disorders Diagnosis Related Group (DRG 287)

The J15 Part A Medical Review department will perform a service-specific complex review on circulatory disorders (DRG Code 287). A Service Specific Probe Edit was conducted. There were 90 claims reviewed, with 43 denied in Kentucky. There were $531,044.34 total reviewed charges, with $240,455.34 denied charges. That resulted in a charge denial rate of 45.3 percent.

There were 98 claims reviewed, with 51 denied in Ohio. There were $600,867.99 total reviewed charges, with $312,188.70 denied charges. This resulted in a charge denial rate of 52 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 five denial reasons identified were:

Denial Code 5J504 — (KY - 43 percent; OH - 49.3 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, but are not limited to the following:
      • Submit documentation to support that all services were medically necessary on an impatient 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 # SE1037External PDF - Guidance on Hospital Inpatient Admission Decisions

Denial Code 56900 - (KY - 2.2 percent)

  • Reason for Denial
    • The medical records were not received in response to an Additional Document Request (ADR) in the required time frame; therefore, we were unable to determine medical necessity
  • How to Avoid a Denial
    • Monitor your claim status on Direct Data Entry (DDE). 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, Zone Program Integrity Contractors (ZPIC), etc. 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 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 ADRs, 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 - (OH - 1.8 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 MD, PA or DO.
    • Electronic signatures are acceptable
  • Orders for inpatient admission written by a non-physician practitioner must be co-signed by the attending physician

5C199 - Billing Error

  • Reason for Denial
    • The services billed were not covered. According to documentation in the medical record, the hospital has billed items and/or services in error. The hospital may not charge the beneficiary for items and/or services that were billed in error.
  • How to Avoid a Denial
    • To avoid future denials for this reason:
      • Check all bills for accuracy prior to submitting to Medicare
      • Ensure that the documentation submitted, in response to the ADR, corresponds with the date that the service/diagnostic test was rendered, and the dates of service billed

For provider outreach and education opportunities please visit:

The Ohio Part A Calendar of Events
The Kentucky Part A Calendar of Events

For education requests please submit an Education Request FormPDF.

Providers who receive an Additional Documentation Request (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

Or fax 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:

  • Hospital history and physical
  • Physician's orders for the admission and all services billed
  • Plan of care
  • Diagnostic test results/reports, including imaging reports
  • Itemized list of all charges
  • Clinical/therapy notes
  • Hospital admission assessment
  • Consultation reports
  • Physician progress notes
  • Hospital discharge summary
  • Please submit all documentation to support the medical necessity of services billed and the DRG code billed.
  • 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 handwritten or an 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 this review may be directed to the Medical Review department at (803) 763-4999.

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