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November 2, 2015

Major Joint Replacement (Medical Severity Diagnosis Related Group (MS-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 (MS-DRG 470) in Kentucky and Ohio from January through March 2015. 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 (MS-DRG 470)

  Charges Claims
Reviewed $2,503,717.64 215
Denied $1,346,886.22 104
Charge Denial Rate 53.8%  

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

  Charges Claims
Reviewed $6,969,843.54 610
Denied $3,194,458.56 271
Charge Denial Rate 45.8%  

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:

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 45 days of the date on the 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.
  • You also have the option to respond to ADRs electronically via the myCGS web portal: PDF.

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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