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November 4, 2013

Cardiac Rehabilitation (CPT Code 93798): Complex Medical Review, Kentucky – Discontinue Complex Review

The J15 Part A Medical Review department performed a service-specific complex review of Cardiac Rehabilitation with Continuous ECG Monitoring (CPT code 93798), type of bill (TOB) 13X, for Kentucky.  Based on the results summarized below, the review will be discontinued.

Kentucky-Complex Edit Results: Cardiac Rehabilitation with Continuous ECG Monitoring (CPT code 93798)
  Charges Claims
Reviewed $371,195.11 261
Denied $106,797.79 89
Charge Denial Rate 28.8%  

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:

5D169/5H169 - Services Not Documented

Reason for denial:

  • This claim was partially or fully denied because the provider billed for services/items not documented in the medical record submitted.

How to prevent denials:

  • Submit all documentation related to the services billed.
  • Ensure that results submitted are for the date of service billed, the correct beneficiary and the specific service billed.

For more information, refer to:

  • Code of Federal Regulations, 42 CFR – Sections 410.32External Website and 424.5External Website

Individual providers with significant denials will be contacted for one-on-one education.

If you have questions regarding this review, please contact the Medical Review department at 803.763.4999.

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