Part A Medical Review Activity Log
| Edit Code | Description | Review Type | Status | Documentation Requirements Checklist |
|---|---|---|---|---|
| 5PE16 | Outpatient pulmonary rehabilitation services (HCPCS codes 94625 & 94626) | Targeted Probe and Educate (TPE) prepayment review | Active | Pulmonary Rehab ADR Checklist |
| 5PE18 | Inpatient psychiatric admissions (DRG 885: Psychoses) | TPE prepayment review | Active | Inpatient Psychiatric Admissions (DRG 885: Psychoses) ADR Checklist |
| 5PE28 | Kidney and UTI with & without MCC (DRGs 689 & 690) | TPE prepayment review | Active | Kidney and UTI with & without MCC (DRGs 689 & 690) ADR Checklist |
| 5PE29 | Heart Failure and Shock with MCC (DRG 291) | TPE prepayment review | Active | Heart Failure and Shock with MCC (DRG 291) ADR Checklist |
| 5PE30 | Inpatient hospital short stay patient status reviews | TPE prepayment review | Pending | Inpatient Hospital Short Stay Patient Status Reviews ADR Checklist |
| 5PE40 | Inpatient Rehabilitation Facility (IRF) | TPE prepayment review | Active | IRF ADR Checklist |
| 5PE41 | Skilled Nursing Facility (SNF) Patient-Driven Payment Model (PDPM) 5-claim review | Probe and educate prepayment review | Completed | PDPM ADR Checklist |
| 5PE45 | SNF PDPM (TOB 21X and revenue code 0022) | TPE prepayment review | Active | PDPM ADR Checklist |
| 5PE47 | Outpatient therapy services (revenue codes 042X, 043X & 044X with modifier KX) | TPE prepayment review | Active | Outpatient Therapy ADR Checklist |
| 5PE48 | Outpatient therapy services (revenue codes 042X, 043X & 044X with modifier KX) | TPE prepayment review | Active | Outpatient Therapy ADR Checklist |
| 5TC3R | Services related to non-covered services/Category III CPT code utilization | Prepayment review | Active | Non-covered Services/Category III CPT Code Utilization ADR Checklist |
Updated: 10.08.2025

