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November 25, 2013

Outpatient Pulmonary Rehabilitation (HCPCS Code G0424): Complex Medical Review, Ohio – Continue Complex Review

The J15 Part A Medical Review department performed a service-specific complex review in Ohio on HCPCS code G0424 (Outpatient Pulmonary Rehabilitation (including exercise/includes monitoring, one hour, therapeutic, prophylactic, or diagnostic), bill type 13X. Based on the results summarized below, the complex edit was continued.  For coverage and documentation requirements related to this review, please refer to the CGS article “Pulmonary Rehabilitation: Coverage and Documentation Requirements.”

Ohio-Complex Edit Results: Outpatient Pulmonary Rehabilitation (HCPCS code G0424)
  Charges Claims
Reviewed $137,097.32 110
Denied $61,274.70 46
Charge Denial Rate 44.7%  

The top denial reasons associated with this review are:

5D901/5H901 – Pulmonary Rehab Not Warranted for Diagnosis

  • Reason for denial:
    • The claim was partially or fully denied because the condition required for coverage of pulmonary rehabilitation services was not submitted in the medical record.
    • The CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 32, section 140.4External PDF, states: “As specified in 42 CFR 410.47, Medicare covers pulmonary rehabilitation items and services for patients with moderate to very severe COPD (defined as GOLD classification II, III, and IV), when referred by the physician treating the chronic respiratory disease.”
  • How to prevent denials:
    • Review the requirements for coverage in the CGS article “Pulmonary Rehabilitation: Coverage and Documentation Requirements.”
    • There must be a clinical evidence of a physician-validated diagnosis that meets the coverage requirement of moderate to very severe COPD, as described in this article.
    • Submit the information required for coverage when responding to the ADR request.

For more information, refer to:

5D902/5H902- Documentation did not Include Required Components

  • Reason for denial:
    • The claim was partially or fully denied because the following components of the pulmonary rehabilitation program were not submitted in the medical record:
      • Physician-prescribed exercise
      • Education or training tailored to the beneficiary’s needs
      • Psychosocial assessment
      • Outcomes assessment
      • An individualized treatment plan  
  • How to prevent denials:
    • Review the requirements for coverage in the CGS article “Pulmonary Rehabilitation: Coverage and Documentation Requirements.”
    • The exercise prescription must include certain required elements.
    • What education factors are relevant and important to the specific patient (e.g., tobacco cessation)?  How were these factors addressed?  Concurrent notes are required to demonstrate how these factors were addressed.
    • Include results of the psychosocial assessment and the physician’s plan of action to address the results.  There are a number of other required elements; refer to the CGS article noted in this section for additional information.
    • Documentation of outcomes assessment must reflect whether the interventions and services did or did not benefit the patient and any related objective measures to demonstrate this.  If the plan was modified as a result of the outcomes assessment, include this documentation as well.
    • An individualized treatment plan must be established, reviewed, and signed at least every 30 days by a physician.  Again, the CGS article provides additional details.  We strongly recommend you review the article in its entirety.

For more information, refer to:

56900 – Records Not Submitted

  • Reason for denial”
    • 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 needed for the claim and submit it all at one time.
    • Submit medical records as soon as the ADR is received.
    • Attach a copy of the ADR 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. Ensure each set of medical records is bound securely so the submitted documentation is not detached or lost.
    • Do not mail packages C.O.D.; we cannot accept them.
    • Return the medical records to the address indicated in the ADR.

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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