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October 8, 2012

Complex Medical Review of Syncope & 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 & collapse.  A service-specific probe edit was conducted in Kentucky for Syncope & Collapse.  There were 101 claims reviewed with 88 claims denied.  There were $340,901.79 charges reviewed with $287,897.61 charges denied resulting in a charge denial rate of 84.5%. Based on this major charge denial rate and total denied charges, this edit will progress to complex in Kentucky. 

Ohio Service-specific Probe Results: Syncope & Collapse (DRG 312)
Charges Claims
Reviewed $340,901.79 101
Denied $287,897.61 88
Charge Denial rate 84.5%  

The top denial reason codes associated with this review are:

Denial Code 5J504 - (82.5%)

  • Reason for denial
    • The documentation submitted for review did not support the medical necessity of the services provided
  • How to prevent denials
    • 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:

Denial Code 56900 - (1.7%)

  • 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 prevent denials
    • 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. Please note: CGS may request records through our Medical Review or Claims departments, and other contractors such as the Zone Program Integrity Contractor (ZPIC) may also request records.  Ensure the records are submitted to the appropriate entity.
    • Alert your mail room 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 you are 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 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 - (0.3%)

  • Reason for denial
    • The services billed were paid at a higher/lower payment level based on medical review of the records submitted.
  • How to prevent denials
    • 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:

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

You may also fax your documentation to 803.462.2596 (use the ADR letter as a cover sheet).

Please ensure that your claims are accurate, and double-check the documentation you are submitting in response to ADRs.  Send the following documentation, as applicable:

  • Hospital History & Physical
  • Physician’s orders for the admission and all services submitted
  • 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
  • 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 the provider of service must be clearly identified on the submitted documentation.  For more information regarding Medicare’s signature requirements, please refer to the CMS Medicare Program Integrity Manual, chapter 3, section PDF.

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

If you have questions regarding this review, please contact the CGS Medical Review department at 803.763.4999.

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