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February 1, 2016

Outpatient Cardiac Rehabilitation with Continuous ECG Monitoring (HCPCS Code 93798): Probe Medical Review -- Kentucky and Ohio

J15A Part A Medical Review will implement a service specific probe edit for type of bill 13X claims related to Outpatient Cardiac Rehabilitation with continuous ECG monitoring in Kentucky and Ohio. Approximately 100 claims will be reviewed for each region.

What to Send

If you receive an Additional Documentation Request (ADR) from CGS, submit the requested medical record information within 45 days. Before you send the requested records, we suggest you double-check the accuracy of your submitted claim.

Send the following documentation when responding to the ADRs, along with other supporting documentation. Please note that the documentation you submit in response to this request should comply with these requirements. This may require you to contact the hospital or other facility where you provided the service and obtain your signed progress notes, plan of care, discharge summary, etc.

  • Physician's orders for all services billed
  • UB-04
  • All physician's orders, nurse's notes, rehab orders/notes, and actual minutes of rehab therapy to support the services billed
  • All diagnostic reports (lab, radiology, cardiology, etc)
  • Any documentation to support medical necessity for continuous ECG monitoring
  • Documentation that the physician was immediately available for each ECG-monitored session billed
  • Documentation of left ventricular ejection fraction of 35% or less
  • Documentation of NYHA Class II-IV symptoms
  • Documentation should include the following components of a cardiac rehabilitation/intensive cardiac rehabilitation program:
    1. Physician-prescribed exercise each day cardiac rehabilitation items and services are furnished (mode of exercise, target intensity, duration of each session, and frequency of sessions)
    2. Cardiac risk factor modification, including education, counseling and behavioral intervention tailored to the patients' individual needs
    3. Psychosocial assessment
    4. Outcomes assessment
    5. An individualized treatment plan detailing how components are utilized for each patient. The individualized treatment plan must be established, reviewed and signed by a physician every 30 days.
  • All documentation as required in the LCD or NCD (if applicable)
  • 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 method used shall be a hand written or an electronic signature. Stamp signatures are not acceptable. Patient identification, date of service, and provider of the service should be clearly identified on the submitted documentation.
  • If the signature requirements are not met, the reviewer will conduct the review without considering the documentation with the missing or illegible signature. This could lead the reviewer to determine that the medical necessity for the service billed has not been substantiated.

Options for Submitting Records

Medical records may be submitted via:

  • Mail. Send the requested records to the address indicated in the ADR letter.
  • Compact disks (CDs) or digital video disks (DVDs). You must use the correct file format of tagged image file format (TIFF), which may be saved to your CD/DVD.
  • Fax to 803.462.2596. Use the ADR letter as a cover sheet.
  • eSMD.
  • myCGS web portal.

Completed review results will be published on the "Probe Medical Reviews" page 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 CGS Part A Provider Contact Center at 866.590.6703.

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