Medical Review Widespread Edits
The goal of CGS's medical review (MR) is to reduce errors by preventing the initial payment of claims that do not comply with Medicare's coverage, coding, payment and billing policies. To achieve the goal of the MR program, we conduct data analysis and evaluate other information. The goals of the data analysis program are to identify provider billing practices and services that pose the greatest risk to the Medicare program.
Providers may conduct self-audits to identify coverage and coding errors using the Office of Inspector General (OIG) Compliance Program Guidelines.
Below are the medical review edits currently in place.
|5037T||This edit selects hospice claims with revenue code 0651 (Routine) and a length of stay of greater than 730 days.|
|5048T||This edit selects hospice claims based on a length of stay of 999 days.|
|5057T||This edit selects hospice claims with revenue code 0656 (General Inpatient Services [GIP]) with at least seven or more days in a billing period.|
|5091T||This edit selects hospice claims with HCPC codes Q5003 (Hospice care provided in nursing long term care facility (LTC) or non-skilled nursing facility (NF)) and Q5004 (Hospice care provided in skilled nursing facility (SNF)), primary diagnosis of 799.3 (Debility, unspecified) and a length of stay greater than 180 days.|
|59BX9||This edit selects hospice claims due to previous denials for selected beneficiary.|
|5023T||This edit selects home health claims for diagnosis 401.9 (Hypertension) and a length of stay greater than 120 days.|
|59BY9||This edit selects home health claims due to previous denials for selected beneficiary.|