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August 11, 2016

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

J15A Part A Medical Review performed a service specific probe edit for claims related to Outpatient Cardiac Rehabilitation with continuous ECG monitoring in Kentucky and Ohio from February through June 2016. Based on the results, the probe edit was advanced to complex edit review in both regions.

Please read this article in its entirety, as the documentation requirements for this review have changed.

Kentucky Probe Edit Results:

  Charges Claims
Reviewed $1,075,402.20 96
Denied $417,767.05 49
Charge Denial Rate 38.8%  

Ohio Probe Edit Results:

  Charges Claims
Reviewed $1,212,127.50 94
Denied $727,922.34 61
Charge Denial Rate 60.1%  

Top Denial Reasons

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 prevent denials:

  • Submit documentation to support all required components of the service when responding to the Additional Documentation Request (ADR).
  • A legible signature is required on all documentation necessary to support orders and medical necessity.
  • Use the most appropriate ICD-10-CM codes to identify the beneficiary's medical diagnosis.
  • Additional tips:
    • During this quarter of review, 24 claims were denied for no documentation of medical necessity.
    • Missing documentation included: physician's orders that specified Phase II Cardiac Rehabilitation and many required components of cardiac rehab, such as detailed exercise notes, psychosocial and outcomes assessments, Individual Treatment Plans, and description of risk factor modifications.
    • Many claims were denied for missing evidence of monitoring. HCPCS code 93798 is Cardiac Rehabilitation with ECG monitoring; therefore, ECG strips must be included with the documentation.
    • When responding to an ADR for this edit, please include all documentation that is relevant to the services billed.
    • CGS published an article, "Cardiac Rehabilitation: Coverage and Documentation Requirements," which defines the requirements and provides other important guidance regarding documentation and claim submission. Refer to this article for clarification of documentation requirements.

For more information, refer to:

5D301 – Physician must be readily available

Reason for denial:

  • The claim was denied because the submitted documentation did not indicate the immediate availability of a physician during billed sessions.

**NOTE: This requirement has been revised to meet CMS standards.**

How to prevent denials:

  • CGS published an article, "Cardiac Rehabilitation: Coverage and Documentation Requirements," which defines physician supervision requirements in hospital-based and non-hospital-based settings and provides other important guidance regarding documentation and claim submission.
  • Upon request, submit the required information based on the setting.
    • The patient's medical record must clearly identify the service as hospital-based or non-hospital-based.
    • The requirements differ by setting. Refer to the CGS web article for additional information.

For more information, refer to:

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). Claims in status/location SB6001 have 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.
  • Ensure your mail room staff is aware of any mail you receive from CGS.
  • Ensure medical records are submitted within 45 days of the date in the upper left corner of the ADR letter.
  • Gather all information and submit at one time.
  • 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.

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 cardiac rehabilitation
  • UB-04 claim form
  • History and physical with documentation of approved diagnoses for cardiac rehabilitation
  • Any documentation that supports medical necessity for continuous ECG monitoring
  • All physician's orders/progress notes, nurse's notes, rehab orders/notes, and actual minutes of rehab therapy to support the services billed
  • All diagnostic reports (lab, radiology, cardiology, etc) specifically ECG tracings
  • Itemized supply or medication lists for all items billed for these dates of service
  • For diagnosis of Congestive Heart Failure (CHF): documentation of left ventricular ejection fraction of 35% or less AND documentation of NYHA Class II-IV symptoms despite being on optimal heart failure therapy for at least 6 weeks
  • 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.

If services are provided in a non hosital-based rehabilitation facility, please submit documentation to support physician supervision (policy and procedure for physician supervision, a calendar/schedule/call log, or other documentation to verify the immediate availability of a physician during the billed services).

If you question the legibility of your signature, you may submit a signature log or an attestation statement in your ADR response. Medicare requires that medical record entries for services provided/ordered be authenticated by the author. The method used shall be a handwritten 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.

The documentation you submit in response to this request should comply with these specified elements. 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.

Options for Submitting Records

Medical records may be submitted on compact disks (CDs) or digital video disks (DVDs) to CGS. Please use the correct file format of tagged image file format (TIFF), which may be saved to a CD/DVD.

Providers may submit records via fax to 803.462.2596. Use the ADR letter as a cover sheet.

Records may also be submitted for review via eSMD.

If you choose to respond by mail, send the requested records to the address indicated in the ADR letter.

Completed review results will be posted on the CGS Complex Medical Reviews page on our website. Individual providers with significant denials will be contacted for one-on-one education.

If you have questions regarding this review, you may contact the CGS Part A Provider Contact Center at 866.590.6703.

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