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May 22, 2017

Cardiac Rehabilitation (HCPCS Code 93798): Complex Medical Review – Kentucky and Ohio – Continued

The J15 Part A Medical Review department performed a service-specific complex review of claims for Cardiac Rehabilitation (HCPCS Code 93798) in Kentucky and Ohio from January through March 2017. Based on the results summarized below, the complex edit review will be continued in Kentucky and Ohio.

Kentucky Service-Specific Complex Edit Results:

  Charges Claims
Reviewed $4,589,204.75 353
Denied $2,511,404.55 197
Charge Denial Rate 54.7%  

Ohio Service-Specific Complex Edit Results:

  Charges Claims
Reviewed $12,647,875.60 1,012
Denied $4,931,562.58 471
Charge Denial Rate 39.0%  

The top denial reasons associated with this review are:

5D261/5H261 – Sessions did not inlcude the required services

  • Reason for denial:
    • This claim was fully denied because one or more of the following components of the cardiac rehabilitation program were not submitted in the medical record:
      • Physician-prescribed exercise
      • Cardiac risk factor modification
      • Psychosocial assessment
      • Outcomes assessment
      • An individualized treatment plan
  • 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.
    • CGS published an article, "Cardiac Rehabilitation: Coverage and Documentation Requirements," which defines the required documentation for each of these elements of cardiac rehabilitation.

For more information, refer to:

5D169/5H169 – Services not documented

  • Reason for denial:
    • This claim was partially or fully denied because the provider billed for services/items not documented in the submitted medical record.
  • How to prevent denials:
    • Submit all documentation related to the services billed when responding to the Additional Documentation Request (ADR).
    • Ensure that results submitted are for the dates of service billed, the correct beneficiary, and the specific service billed.

For more information, refer to:

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 routes any mail you receive from CGS to the appropriate person/department for handling.
    • 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.

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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