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August 6, 2013

Chronic Obstructive Pulmonary Disease (COPD) without Complication or Comorbidity(CC)/Major Complication or Comorbidity (MCC)/((Diagnosis Related Group (DRG) 192): Results of Complex Medical Review, Ohio

The J15 Part A Medical Review department performed a service-specific complex review on Chronic Obstructive Pulmonary Disease without CC/MCC in Ohio from February through April 2013. Based on the results summarized below, the complex edit review will continue in Kentucky.

Ohio Service-specific Complex Edit Results: COPD without Major complication or Comorbidity, DRG 192
  Charges Claims
Reviewed $864,430.14 245
Denied $669,000.03 196
Charge Denial Rate 77.4%  

The top denial reasons associated with this review are:

Denial Code 5J504 - Need for Service/Item Not Medically and Reasonably Necessary (97.56 percent of dollars denied)

Denial Code 56900 - Requested Records Not Submitted (2.44 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 handwritten 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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