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October 16, 2013

Esophagitis Gastroenteritis (Diagnosis Related Group (DRG) 391-392), Ohio - Discontinued

The J15 Part A Medical Review department performed a service-specific complex review on Esophagitis/Gastroenteritis (DRG 391-392) in Ohio from March through May 2013. Based on a Recovery Audit Prepay Demonstration, this edit has been discontinued in Ohio.

Ohio Service-specific Complex Edit Results: Esophagitis Gastroenteritis, DRG 391-392
  Charges Claims
Reviewed $1,170,330.67 275
Denied $952,995.78 226
Charge Denial Rate 81.4%  

The denial reasons associated with this edit are:

Denial Code 5J504 Need for Service/Item not medically and reasonably necessary (Percentage of dollars denied: 98.20%)

  • Reason for denial:
    • The documentation submitted for review did not support the medical necessity of the services provided.
  • How to prevent denials:
    • Submit documentation to support that all services were medically necessary on an inpatient basis instead of a less intensive setting.
    • Documentation should include all clinical information for the dates of service billed such as physician progress notes, physical examinations, assessments, diagnostic tests and laboratory test results, history and physical, nurse’s notes, consultations, surgical procedures, orders and discharge summary and any other documentation to support the inpatient admission.
    • Include documentation of services, medication and medical interventions performed in the Emergency Department.
    • For elective surgical procedures, include documentation to support the necessity of the procedure including pre-surgical interventions and outcomes.
  • For more information, refer to:

Denial Code 56900 Requested Records Not Submitted (Percentage of dollars denied: 1.80%)

  • Reason for denial:
    • The medical records were not received in response to an Additional Documentation 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 Unified Program Integrity Contractor (UPIC) 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.

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.

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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