CorporateBusiness Services

August 9, 2012 - Revised: 10.02.13

Complex Medical Review of Syncope and Collapse Diagnosis Related Group Diagnosis Related Group (DRG) 312

The J15 Part A Medical Review department will perform a service-specific inpatient complex review on syncope and collapse. A service specific probe edit was conducted in Ohio for syncope and collapse. There were 111 claims reviewed, with 93 claims denied. There were $403,068.84 charges reviewed, with $321,901.46 charges denied. This resulted in a charge denial rate of 79.9 percent. Based on this high charge denial rate and total denied charges, this edit will progress to complex in Ohio. The top four denial reasons identified were:

Denial Code 5J504 (73.2 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 # SE1037-Guidance on Hospital Inpatient Admission DecisionsExternal PDF

Denial Code 5J503 (3.7 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 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

Denial Code 56900 (2.7 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 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 cannot accept them
    • Return the medical records to the address indicated in the ADR. Be sure to include the appropriate mail code.

5CHGE - DRG Upcode/Downcode (0.1 percent)

  • Reason for Denial
    • The services billed were paid at a higher/lower payment level based on medical review of the records submitted
  • How to Avoid a Denial
    • Under the Prospective Payment System (PPS), Medicare reimbursement rates are based on the patient's health condition and care needs
    • Submit orders to cover the procedures billed
    • Submit all documentation related to the services rendered
  • For more information, refer to:
    • CMS Internet-Only Manuals (IOMs), Pub 100-08, Medicare Program Integrity Manual, Chapter 6, Section 6.5.3

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 20021
Nashville, TN 37202

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

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:

  • 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 hand written 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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