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May 6, 2016

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 of claims for Major Joint Replacement (DRG 470) in Kentucky and Ohio from December 2015 through February 2016. Based on the results summarized below, the targeted medical review edit will be continued in Kentucky and Ohio.

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

  Charges Claims
Reviewed $881,480.82 81
Denied $491.981.11 26
Charge Denial Rate 55.8%  

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

  Charges Claims
Reviewed $2,002,337.85 175
Denied $790,643.80 48
Charge Denial Rate 39.5%  

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 in 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 route any mail you receive from CGS to the appropriate department for handling.
    • Submit medical records as soon as the ADR is received, but no later than 45 days of the date on the ADR letter (located in the upper left corner).
    • Gather all information needed for the claim and submit it all at one time.
    • Attach a copy of the ADR letter to each individual claim.
    • If responding to multiple ADRs, separate each response and attach a copy of the ADR letter 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 C.O.D.; we cannot accept them.
    • Return the medical records to the address indicated in the ADR letter and 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 the CGS Part A Provider Contact Center at 866.590.6703.

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