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October 16, 2013

Cardiac Rehabilitation with Continuous ECG Monitoring (CPT Code 93798)- Ohio: Complex Medical Review - Discontinued

The J15 Part A Medical Review department has performed a service-specific complex review on Cardiac Rehabilitation, CPT code 93798, revenue code 94X, bill type 13X for Outpatient Cardiac Rehab with Continuous ECG Monitoring in Ohio from March through May 2013.  Based on the results summarized below, this edit has been discontinued in Ohio.

Ohio-Complex Medical Review of Cardiac Rehab with Continuous ECG Monitoring (CPT Code 93798)
  Charges Claims
Reviewed $1,049,948.92 793
Denied $300,938.75 264
Charge Denial Rate 28.7%  

The top denial reasons associated with this review are:

5D241/5H241 – Cardiac Rehab Not Warranted for Diagnosis

Reason for denial:

  • The claim was fully denied because the condition required for coverage of cardiac rehabilitation services was not submitted in the medical record.
    • Medicare coverage of cardiac rehabilitation services is defined in the Code of Federal Regulations (42 CFR 410.49). Coverage for cardiac rehabilitation services is limited to patients with one or more of the following:
    • Acute myocardial infarction within the preceding 12 months; or
    • Coronary artery bypass surgery; or
    • Current stable angina pectoris; or
    • Heart valve repair or replacement; or
    • Percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting; or
    • Heart or heart-lung transplant
  • How to prevent denials:
    • Upon request, submit documentation to substantiate that one or more of the above criteria are met
    • Note: this may require obtaining records from the referring physician

For more information, refer to:

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-Requested records not submitted  

  • Reason for denial:
    • The medical records were not received in response to an Additional Development Request (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.

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. 
    • If the signature requirements are not met, we will conduct the review without considering the documentation with the missing or illegible signature. This may lead us to determine that the medical necessity for the service billed has not been substantiated.
    • For more information regarding signature requirements for Medicare purposes, refer to the CMS Medicare Program Integrity Manual (Pub. 100-08), chapter 3, section PDF and CMS MLN Matters article MM6698External PDF, “Signature Requirements for Medical Review Purposes.”

Options for Submitting Records

  • You may submit medical records compact disks (CDs) or digital video disks (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 short stay inpatient reviews, please call the Medical Review department at 803.763.4999.

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