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December 9, 2013

Inpatient Services for Percutaneous Transluminal Coronary Angioplasty (PTCA) without Stent-Diagnosis Related Group (DRG) 251: Complex Review, Kentucky and Ohio – Continued

The J15 Part A Medical Review department conducted a service-specific complex edit on inpatient services for DRG 251 (PTCA without Stent), type of bill 11X, in Kentucky and Ohio. Based on the results summarized below the complex edit was continued in both regions.

Kentucky-Complex Edit Results: PTCA without Stent (DRG 251)
  Charges Claims
Reviewed $41,320.37 4
Denied $18,676.82 2
Charge Denial Rate 45.2%  
Ohio-Complex Edit Results: PTCA without Stent (DRG 251)
  Charges Claims
Reviewed $332,260.87 27
Denied $190,071.68 16
Charge Denial Rate 57.2%  

The top denial reason identified was:

Denial Code 5J504 - Service Not Medically Reasonable and Necessary

  • 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, if applicable.
    • For elective surgical procedures, include documentation to support the necessity of the procedure including pre-surgical interventions and outcomes. Please note: this may require obtaining information from the admitting physician
  • For more information, refer to:

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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