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April 28, 2015

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 October through December 2014.  Based on the results summarized below, the targeted medical review edit was continued in Kentucky and Ohio.

Kentucky Service-Specific Complex Edit Results:  Major Joint Replacement (DRG 470)

 

Charges

Claims

Reviewed

$6,288,799.06

526

Denied

$3,831,719.07

321

Charge Denial Rate

60.9%

 

Ohio Service-Specific Complex Edit Results:  Major Joint Replacement (DRG 470)

 

Charges

Claims

Reviewed

$17,257,484.89

1470

Denied

$10,687,826.52

903

Charge Denial Rate

61.9%

 

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.

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

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

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