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February 28, 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 October through December 2016. 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 $1,682,317.21 123
Denied $937,072.28 67
Charge Denial Rate 55.7%  

Ohio Service-Specific Complex Edit Results:

  Charges Claims
Reviewed $5,339,379.38 432
Denied $2,496,506.34 227
Charge Denial Rate 46.8%  

The top denial reasons associated with this review are:

5D261 – 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:

5D301 – Physician must be readily available

  • Reason for denial:
    • This claim was partially or fully denied because the documentation did not support that the program was under the direct supervision of a physician.
  • How to prevent denials:
  • Submit all documentation related to the services billed when responding to the Additional Documentation Request (ADR).
  • CGS published an article, "Cardiac Rehabilitation: Coverage and Documentation Requirements" which defines physician supervision requirements in hospital-based and non-hospital-based settings and provides other important guidance regarding documentation and claim submission.
  • Upon request, submit the required information based on the setting:
    • The patient's medical record must clearly identify the service as hospital-based or non-hospital-based.
    • The requirements differ by setting. Refer to the CGS web article for additional information.

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 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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