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September 26, 2014

Major Joint Replacement (Diagnosis Related Group (DRG) 470): Complex Medical Review – Kentucky and Ohio

The J15 Part A Medical Review department performed a service-specific complex review on claims for Major Joint Replacement (DRG 470) in Kentucky and Ohio from September through December 2013. Based on the results summarized below, the complex edit review will be continued in Kentucky and Ohio.

Kentucky Service-Specific Complex Edit Results: Major Joint Replacement (DRG 470)
  Charges Claims
Reviewed $1,248,643.98 103
Denied $384,277.79 31
Charge Denial Rate 30.8%  

Ohio Service-Specific Complex Edit Results: Major Joint Replacement (DRG 470)
  Charges Claims
Reviewed $3,126,231.75 271
Denied $1,256,329.58 105
Charge Denial Rate 40.2%  

The top denial reasons associated with this review are:

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

Denial Code 56900 - Requested Records Not Submitted

  • 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 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. Be sure to include the appropriate mail code.

If you receive an ADR from CGS, submit the requested medical record information within 30 days. Before you send the requested records, we suggest you double-check the accuracy of your submitted claims.

Send the following documentation when responding to the ADRs, along with other supporting documentation. Please note: the documentation you submit in response to this request should comply with these requirements:

  • Hospital history and physical
  • Physician's orders for the admission and all services submitted
  • Plan of care
  • Diagnostic test results/reports, including imaging reports
  • Itemized list of all charges
  • Clinical/therapy notes
  • Hospital admission assessment
  • Consultation reports
  • Physician progress notes
  • Hospital discharge summary
  • For elective surgical procedures, include documentation to support the necessity of the procedure including pre-surgical interventions and outcomesas described in CMS MLN Matters article MMSE1236, "Documenting Medical Necessity for Major Joint Replacement (Hip and Knee)."
  • 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 record 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 must 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 Medicare's signature requirements, please refer to the CMS Medicare Program Integrity Manual (Pub. 100-08), chapter 3, section and CMS MLN Matters article MM6698, "Signature Requirements for Medical Review Purposes."

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 803.432.2596. 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.

Completed review results will be posted on the CGS website. Individual providers with significant denials will be contacted for one-on-one education.

If you have questions regarding this review, please call the CGS Part A Provider Contact Center at 866.590.6703.

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