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August 11, 2016

Urinary Stent Placement (HCPCS Code 52332): Complex Review – Kentucky and Ohio – Discontinue

The J15 Part A Medical Review department performed a service-specific complex review of claims for Urinary Stent Placement (HCPCS Code 52332) in Kentucky and Ohio from March through June 2016. Based on the results summarized below, the complex edit review was discontinued in Kentucky and Ohio.

Kentucky Complex Edit Results

  Charges Claims
Reviewed $686,586.29 179
Denied $89,200.87 17
Charge Denial Rate 13.0%  

Ohio Complex Edit Results

  Charges Claims
Reviewed $1,711,143.02 348
Denied $160,077.34 24
Charge Denial Rate 7.8%  

The top denial reasons associated with this review were:

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 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.

For more information, refer to:

5C199 – Billing Error

Reason for denial:

  • The services billed were not covered. According to documentation in the medical record, the hospital has billed items and/or services in error. The hospital may not charge the beneficiary for items and/or services that were billed in error.

How to prevent denials:

  • Check all claims for accuracy prior to submitting to Medicare.
  • Ensure that the documentation submitted in response to the ADR corresponds with the date that the service/diagnostic test was rendered and the dates of service billed.

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.
  • 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.

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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