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May 24, 2013

Cardiac Rehabilitation (CPT Code 93798): Complex Medical Review Results, Ohio

The J15 Part A Medical Review department performed a service-specific complex review on Cardiac Rehabilitation, CPT code 93798, revenue code 94X, Type of Bill (TOB) 13X, for Outpatient Cardiac Rehab with Continuous ECG Monitoring in Ohio. Based on the results summarized below and the moderate charge denial rate, this edit will be continued in Ohio. For related information, please refer to the article "Cardiac Rehabilitation: Coverage and Documentation Requirements."

Ohio-Complex Medical Review of Cardiac Rehab with Continuous ECG Monitoring (CPT Code 93798)
Charges Claims
Reviewed $1,152,898.08 931
Denied $510,111.87 468
Charge Denial Rate 44.2%

The top denial reasons associated with this review:

5D241/5H241 - Cardiac Rehab Not Warranted for Diagnosis (13.54 percent of dollars denied)

5D261/5H261 - Sessions Did Not Include the Required Services (63.11 percent of dollars denied)

Reason for denial:

  • This claim was fully denied because one or more of the following components of the cardiac rehabilitation program were not submitted in the medical record:
  • Physician-prescribed exercise
  • Cardiac risk factor modification
  • Psychosocial assessment
  • Outcomes assessment
  • An individualized treatment plan

How to prevent denials:

  • CGS published an article, "Cardiac Rehabilitation: Coverage and Documentation RequirementsExternal Website," which defines the required documentation for each of these elements of cardiac rehabilitation.
    • We strongly recommend you review this article in its entirety.
    • Upon request, provide supporting documentation for all required elements

For more information, refer to:

5D301/5H301 - Physician must be readily available (8.95 percent of dollars denied)

  • Reason for denial:
    • The claim was denied because the requirement for cardiac rehabilitation services regarding "the program must be under the direct supervision of a physician" was not met.
  • How to prevent denials:
    • CGS published an article, "Cardiac Rehabilitation: Coverage and Documentation RequirementsExternal Website" which defines physician supervision requirements in hospital-based and non-hospital-based settings and provides other important guidance regarding documentation and claim submission
    • Upon request, submit the required information based on the setting
      • The patient's medical record must clearly identify the service as hospital-based or non-hospital-based
      • The requirements differ by setting. Refer to the CGS Web article for additional information

For more information, refer to:

56900 - Requested records not submitted (8.20 percent of dollars denied)

  • 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

If you receive a request for medical records, please submit the following information within 30 days to the address on the ADR:

  • Physician's orders for the admission and all services billed
  • Itemized list of charges
  • Hospital admission assessment and hospital discharge summary
  • Hospital history and physical
  • Physician progress notes
  • Consultation reports
  • Plan of care
  • Diagnostic test results/reports, including imaging reports
  • Clinical/therapy notes
  • Please submit all documentation to support the medical necessity of services billed and the DRG code billed
  • A signature log or an attestation statement, if you question the legibility of your signature. Medicare requires that medical records entries for services provided/ordered be authenticated by the author. The signature may be hand-written or electronic; stamp signatures are not acceptable. Patient identification, date of service, and provider of the service should be clearly identified on the submitted documentation.

Options for Submitting Records

You may submit medical records compact discs (CDs) or digital video discs (DVDs) to CGS. You must use the correct file format of tagged image file format (tiff), which may be saved to your CD/DVD.

You may also submit records via fax to: (803) 462-2596. Use the ADR letter as a cover sheet.

If you choose to respond by mail, send the requested records to the address indicated in the ADR letter.

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 CGS Medical Review department at (803) 763-4999.

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