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February 28, 2017

Major Joint Replacement (Medicare Severity Diagnosis Related Group (MS-DRG) 470): Complex Medical Review – Kentucky – Continued

The J15 Part A Medical Review department performed a service-specific complex review of claims for Major Joint Replacement (MS-DRG 470) in Kentucky from October through December 2016. Based on the results summarized below, the targeted medical review edit was continued in Kentucky.

Kentucky Service-Specific Complex Edit Results:

  Charges Claims
Reviewed $548,185.12 48
Denied $161,157.55 314
Charge Denial Rate 29.4%  

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). 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. Be sure to 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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