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June 13, 2013

Cardiac Rehabilitation (CPT Code 93798): Complex Medical Review Results - Kentucky

The J15 Part A Medical Review department continued the service-specific complex review of Cardiac Rehabilitation with Continuous ECG Monitoring (CPT code 93798), revenue code 94X, type of bill (TOB) 13X, for Kentucky. Based on the results summarized below, this edit will be continued. For related information, please refer to the article 'Cardiac Rehabilitation: Coverage and Documentation Requirements.'

Kentucky Service-specific Complex Edit Results: Cardiac Rehabilitation with Continuous ECG Monitoring (CPT code 93798)
Charges Claims
Reviewed $502,578.11  386
Denied $220,961.13  193
Charge Denial Rate 44.0%  

The top three denial reasons associated with this review are:

5D261/5H261 – Sessions Did Not Include the Required Services

  • 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 Requirements,' 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:

56900 - Auto Deny – Requested Records Not Submitted

  • Reason for denial:
    • The services billed were not covered because the claim was not submitted or not submitted timely in response to an Additional Development Request (ADR). You must respond to ADRs within 30 days from the date on the letter and provide the requested documentation. In accordance with CMS instructions, if the documentation needed to make a medical review determination is not received within 45 days from the date of the documentation request, CGS will make a medical review determination based on the available medical documentation. If the claim is denied, payment will be denied or an overpayment will be collected.
  • How to prevent denials:
    • Be aware of the ADR date and the need to submit medical records within 30 days of the ADR date
    • Submit the medical records as soon as the ADR is received
    • Monitor the status of your claims in Direct Data Entry (DDE) and begin gathering the medical records as soon as the claim goes to the location of SB6001
    • Return the medical records to the address on the ADR. Be sure to include the appropriate mail code or station number. This ensures that your responses are promptly routed to the Medical Review department.
    • Gather all of the information needed for the claim and submit it all at one time
    • Attach a copy of the ADR request 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. Make sure each set of medical records is bound securely with one staple in the upper left corner or a rubber band to ensure that no documentation is detached or lost. Do not use paper clips.
    • Do not mail packages C.O.D.; we cannot accept them.

5D241/5H241 – Cardiac Rehab Not Warranted for Diagnosis (13.74 percent of dollars denied)

Tips for Submitting Documentation

  • If you receive an Additional Documentation Request (ADR) letter, 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
    • Any documentation that supports medical necessity for cardiac 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 CGS Web article 'Cardiac 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. For further guidance regarding signature requirements, refer to:

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

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