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Corporate

August 2, 2012 - Revised: 10.02.13

Complex Medical Review of Outpatient Pulmonary Rehabilitation, Including Exercise (Includes Monitoring), One Hour, Therapeutic, Prophylactic or Diagnostic (G0424)

The J15 Part A Medical Review department will perform a service-specific complex review on outpatient pulmonary rehabilitation. The review will include exercise (includes monitoring), one hour, therapeutic, prophylactic, or diagnostic (HCPCS G0424). A service-specific probe edit was conducted for HCPCS code G0424 revenue code 94X, bill type 13X for Kentucky. There were 100 claims reviewed, with 88 denied.

There were $98,822.03 total charges reviewed with $83,224.61 charges denied. This resulted in a charge denial rate of 84.2 percent. Based on the high charge denial rate and total denied charges this edit will progress to Complex Service Specific in Kentucky.

The top four denial codes are:

5D901/5H901 - (49.3 percent)

  • Reason for Denial
    • The claim was fully denied because the condition required for coverage of pulmonary rehabilitation services was not submitted in the medical record
    • CMS Manual System, Pub 100-04, Medicare Claims Processing Manual, Chapter 32, Section 140.4 states 'As specified in 42 CFR 410.47, Medicare covers pulmonary rehabilitation items and services for patients with moderate to very severe COPD (defined as GOLD classification II, III and IV), when referred by the physician treating the chronic respiratory disease.
  • How to Avoid a Denial
    • Submit the information required for coverage when responding to the Additional Documentation Request (ADR)

For more information, refer to:

  • CMS Internet-Only Manuals (IOMs), Publication 100-04, Medicare Claims Processing Manual, Chapter 32, Section 140.4

5D902/5H902 - (19.5 percent)

  • Reason for Denial
    • This claim was fully denied because the following components of the pulmonary rehabilitation program were not submitted in the medical record:
      • Physician-prescribed exercise
      • Education or training
      • Psychosocial assessment
      • Outcomes assessment
      • An individualized treatment plan
  • How to Avoid a Denial
    • Submit the program component requirements when responding to the ADR

For more information, refer to:

  • CMS Internet-Only Manuals (IOMs), Publication 100-04, Medicare Claims Processing Manual, Chapter 32, Section 140.4
  • Change Request (CR) 6823
  • CMS Medicare Learning Network (MLN) Matters article MM6823 (Pulmonary Rehabilitation Services)

Denial Code 56900 - (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 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.

5D903/5H903 - (8.9 percent)

  • Reason for Denial
    • The claim was denied because the requirement for pulmonary rehabilitation services regarding 'the program must be under the direct supervision of a physician' was not met
  • How to Avoid a Denial
    • Provide documentation that the physician is present in the facility and immediately available to furnish assistance and direction throughout the performance of the procedure

For more information, refer to:

  • CMS Internet-Only Manuals (IOMs), Publication 100-04, Medicare Claims Processing Manual, Chapter 32, Section 140.4
  • Code of Federal Regulations, 42 CFR – Section 410.32 (b)(3)(ii)

For provider outreach and education opportunities please visit:

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:

CGS
J15 Part A Medical Review
Mail Code: AG-735
P.O. Box 20021
Nashville, TN 37202

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

CGS
J15 Part A Medical Review
Mail Code: AG-735
Two Vantage Way
Nashville, TN 37228

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:

  • Physician's orders for all services billed
  • UB-04
  • Any documentation that supports medical necessity for pulmonary rehabilitation
  • Documentation that the physician was immediately available for each monitored session billed
  • Documentation of the actual in/out times for each session billed
  • Nurse's notes
  • Progress notes
  • Lab reports
  • X-ray reports (if applicable)
  • Radiology test results
  • Therapy notes (if applicable)
  • Any other diagnostic reports
  • Itemized supply or medication lists for all items billed for these dates of service
  • Please submit all documentation as required in the LCD or NCD (if applicable)
  • 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.
  • Please submit a copy of an advanced beneficiary notice (ABN), if issued

Completed review results will be posted at www.cgsmedicare.com/parta. 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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