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December 9, 2013

Inpatient Services for Simple Pneumonia and Pleurisy-Diagnosis Related Group (DRG) 195: Complex Review, Kentucky and Ohio - Continued

The J15 Part A Medical Review department performed a service-specific complex review on inpatient services for DRG 195 (Simple Pneumonia and Pleurisy), type of bill 11X, in Kentucky and Ohio. Based on the results summarized below, the complex edit review was continued in both regions.

Kentucky-Complex Edit Results: Pneumonia & Pleurisy (DRG 195)
  Charges Claims
Reviewed $305,587.55 97
Denied $168,926.16 54
Charge Denial Rate 55.2%  
Ohio-Complex Edit Results: Pneumonia & Pleurisy (DRG 195)
  Charges Claims
Reviewed $522,585.13 155
Denied $261,609.30 77
Charge Denial Rate 50.0%  

The top denial reasons associated with this review are:

Denial Code 5J504 - Need for Service/Item Not Medically and Reasonably Necessary

  • Reason for denial:
    • The documentation submitted for review did not support the medical necessity of the services provided.
  • How to prevent denials:
      • Documentation and tips that may be helpful to avoid future denials for this reason may include, but are not limited to the following:
      • 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

  • 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.

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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