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November 2, 2015

Urinary Stent Placement (CPT Code 52332): Complex Review – Ohio - Continue Complex Review

The J15 Part A Medical Review department performed a service-specific complex review on claims for Urinary Stent Placement (CPT Code 52332) in Ohio from January through March 2015. Based on the results summarized below, the complex edit review was continued in Ohio.

Ohio Complex Edit Results: Urinary Stent Placement (CPT Code 52332)

  Charges Claims
Reviewed $421,633.87 85
Denied $128,753.16 23
Charge Denial Rate 30.5%  

The top denial reasons associated with this review are:

Denial Code 5D164/5H164 – No documentation of medical necessity

Reason for denial:

  • This claim was fully or partially denied because the documentation submitted for review does not support the medical necessity of some of the services billed.

How to avoid denials:

  • Submit documentation to support all required components of the service when responding to the Additional Documentation Request (ADR).
  • A legible, handwritten signature is required on all documentation necessary to support orders and medical necessity.
  • Use the most appropriate ICD-9-CM/ICD-10-CM codes to identify the beneficiary's medical diagnosis.

For more information, refer to:

  • CMS Medicare Program Integrity Manual (Pub. 100-08), Chapter 3, Section
  • CMS MLN Matters Article MM6698, Signature Guidelines for Medical Review Purposes
  • Definition of "medically necessary": Social Security Act (SSA), Section 1862 (a)(1)(A)
  • Code of Federal Regulations: 42 CFR 410.32

5D169/5H169 — Services not documented

Reason for denial:

  • Claims fully or partially denied because the provider billed for services/items not documented in the medical record submitted.

How to avoid denials:

  • Submit all documentation related to the services billed.
  • Ensure that results submitted are for the date of service billed, the correct beneficiary and the specific service billed.

For more information, refer to:

  • Code of Federal Regulations: 42 CFR 410.32 and 424.5External PDF

Denial Code 56900- Requested records not submitted

Reason for denial:

  • The medical records were not received in response to an ADR in the required timeframe; therefore, we were unable to determine medical necessity.

How to avoid 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.
  • You also have the option to respond to ADRs electronically via the myCGS web portal.  

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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