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April 24, 2013

Outpatient Pulmonary Rehabilitation (HCPCS G0424): Complex Medical Review

The J15 Part A Medical Review department will continue the service-specific complex review in Kentucky on HCPCS code G0424 (outpatient Pulmonary rehabilitation, including exercise (includes monitoring), one hour, therapeutic, prophylactic or diagnostic. A service-specific complex edit was conducted for HCPCS code G0424 revenue code 94X, Type of Bill (TOB) 13X, for Kentucky from November 2012 through January 2013.

Based on the results summarized below, this will continue as a Complex Service Specific edit in Kentucky. For coverage and documentation requirements related to this review, please refer to the CGS article "Pulmonary Rehabilitation: Coverage and Documentation Requirements."

Kentucky Service-specific Complex Edit Results: Outpatient Pulmonary Rehabilitation, including exercise (includes monitoring), one hour, therapeutic, prophylactic or diagnostic (HCPCS code G0424)
  Charges Claims
Reviewed $102,903.79 139
Denied $86,214.09 116
Charge Denial Rate 83.8%  

The top denial reasons associated with this review are:

5D901/5H901 - Pulmonary Rehab Not Warranted for Diagnosis - (65.18 percent of denied dollars)

5D903/5H903 - Physician must be readily available - (14.31 percent of denied dollars)

  • 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
    • There are specific physician supervision requirements for hospital-based settings and non-hospital-based settings
  • How to prevent denials:
    • Ensure that the setting (hospital-based or non-hospital-based) is clear in the documentation you submit
    • For hospital-based settings, it is presumed that a physician is immediately accessible for medical consultation and medical emergencies
    • For non-hospital-based settings, documentation of direct physician supervision must meet the standard defined in the Code of Federal Regulations (42 CFR 410.27). 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:

5D902/5H902 - Documentation did not Include Required Components - (9.99 percent of denied dollars)

  • 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 tailored to the beneficiary's needs
      • Psychosocial assessment
      • Outcomes assessment
      • An individualized treatment plan
  • How to prevent denials:
    • Review the requirements for coverage in the CGS article "Pulmonary Rehabilitation: Coverage and Documentation Requirements."
    • The exercise prescription must include certain required elements
    • What education factors are relevant and important to the specific patient (e.g., tobacco cessation)? How were these factors addressed? Concurrent notes are required to demonstrate how these factors were addressed.
    • Include results of the psychosocial assessment and the physician's plan of action to address the results. There are a number of other required elements; refer to the CGS article noted in this section for additional information.
    • Documentation of outcomes assessment must reflect whether the interventions and services did or did not benefit the patient and any related objective measures to demonstrate this. If the plan was modified as a result of the outcomes assessment, include this documentation as well.
    • An individualized treatment plan must be established, reviewed, and signed at least every 30 days by a physician. Again, the CGS article provides additional details. We strongly recommend you review the article in its entirety.
  • For more information, refer to:

56900 - Requested Records Not Submitted - (5.18 percent of denied dollars)

  • Reason for denial:
    • The medical records were not received in response to an ADR in the required timeframe. 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 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.

Tips for Submitting Documentation

  • If you receive an ADR, submit the requested medical record information within 30 days to the address on the ADR. You may also fax your documentation to (803) 462-2596 (use the ADR letter as a cover sheet).
  • Ensure that your claim is accurate and that you are submitting supporting documentation to show that all coverage requirements are met. This includes (but is not limited to):
    • 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 (refer to the CGS article "Pulmonary Rehabilitation: Coverage and Documentation Requirements.")
    • 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.
    • If the patient signed an Advance Beneficiary Notice of Noncoverage (ABN), include a copy with your submitted documentation

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

If you have questions regarding this review, please contact the Medical Review department at (803) 763-4999.

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