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August 11, 2016

Resource Utilization Group (RUG) Codes RUA, RUB and RUC: Complex Review – Ohio – Continue

The J15 Part A Medical Review department performed a service-specific complex review of Resource Utilization Group (RUG) Codes RUA, RUB and RUC in Ohio from March through June 2016. Based on the results summarized below, the complex review was continued in Ohio.

Ohio Complex Edit Results:

  Charges Claims
Reviewed $81,466.80 33
Denied $29,332.12 15
Charge Denial Rate 36.0%  

The top denial reasons associated with this review:

5D504 – Need for Service/Item Not Medically and Reasonably Necessary

Reason for Denial:

  • The documentation submitted for review did not support the medical necessity of the services provided.

How to Avoid a Denial:

  • Documentation and tips that may be helpful to avoid future denials for this reason may include, but are not limited to, the following:
    • Submit documentation to support that all services were medically necessary on an inpatient basis instead of a less intensive setting.
    • Documentation should include all clinical information for the dates of service billed, such as: physician progress notes, physical examinations, assessments, diagnostic tests and laboratory test results, history and physical, nurse's notes, consultations, surgical procedures, orders and discharge summary and any other documentation to support the inpatient admission.
    • Include documentation of services, medication and medical interventions performed in the Emergency Department.
    • For elective surgical procedures, include documentation to support the necessity of the procedure, including pre-surgical interventions and outcomes.
  • For additional information, please reference:

56900 – Medical Records Not Submitted

Reason for Denial:

  • Medical records were not received in response to an Additional Documentation Request (ADR) within the required time frame; therefore, we were unable to determine medical necessity.

How to Avoid a Denial:

  • Monitor your claim status in Direct Data Entry (DDE). Claims in status/location SB6001 have been selected for review by CGS 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 that do not appear in the SB6001 location. 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.
  • Options for submitting records:
  • 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.
  • If you choose to respond by mail, send the requested records to the address indicated in the ADR letter.
  • myCGS web portal

5DOWN/MRDWN – Medical Review Downcode

Reason for Denial:

  • The services billed were paid at a lower payment level. Documentation submitted for review should support the data on the MDS, paint a clear picture of the beneficiary's medical condition, and meet coverage criteria. Based on medical review, the documentation submitted for review did not meet the criteria for the RUG code(s) billed. As a result, reimbursement has been adjusted to a lower payment level.

How to Avoid a Denial:

  • Submit all documentation to support the RUG code(s) billed.
  • The MDS assessment that established the RUG code billed must be supported by the clinical documentation
  • If any portion of the documentation to support the RUG code billed is not submitted, CGS may downcode the RUG.
  • When therapy RUG codes are billed, the following documentation must be submitted for review:
  • Orders for therapy services signed and dated by the physician
  • A written therapy plan of treatment established by the physician after consultation with the therapist
  • The actual minutes of therapy rendered as documented on a log/grid or in the clinical documentation to support the minutes recorded on the MDS
  • Progress notes and any other documentation to establish the medical necessity of the services rendered

For additional information, please reference:

Individual providers with significant denials will be contacted for one-on-one education.

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


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