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May 31, 2012 - Revised: 09.30.13

Complex Medical Review of Outpatient Cardiac Rehabilitation with Continuous ECG Monitoring (93798)

The J15 A Medical Review department will perform a service-specific complex review on outpatient cardiac rehabilitation with continuous ECG monitoring claims (HCPCS 93798). A Service Specific Probe Edit was conducted in Ohio and there were 100 claims reviewed with 96 denied resulting in a charge denial rate of 92.5 percent. The total charges reviewed were $127,512.02 and total denied were $117,512.02. Based on the high charge denial rate and total denied charges, this edit will progress to Complex Service Specific in Ohio.

The top five denial reasons identified were:

Denial Code 5D301/5H301 - (46.8 percent)

Reason for Denial

The claim was denied because the requirement for cardiac rehabilitation services regarding 'the program must be under the direct supervision of a physician' was not met.

How to Avoid a Denial

Provide documentation that the physician is present in the facility and immediately available to furnish assistance and direction throughout the performance of the procedure

For more information, refer to:

  • CMS Internet-Only Manuals (IOMs), Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 1, Section 20.10
  • CMS Internet-Only Manuals (IOMs), Publication 100-04, Medicare Claims Processing Manual, Chapter 32, Section 140
  • Code of Federal Regulations, 42 CFR – Section 410.32 (b)(3)(ii)

Denial Code 5H261 - (25.8 percent)

Reason for Denial

This claim was fully denied because 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 Avoid a Denial

  • Submit the program component requirements when responding to the ADR request

For more information, refer to:

  • CMS Internet-Only Manuals (IOMs), Publication 100-04, Medicare Claims Processing Manual, Chapter 32, Section 140.2
  • Change Request 6850
  • CMS Medicare Learning Network (MLN) Matters article MM6850 (Cardiac Rehabilitation and Intensive Cardiac Rehabilitation

Denial Code 5H241 - (15.3 percent)

Reason for Denial

The claim was fully denied because the condition required for coverage of cardiac rehabilitation services was not submitted in the medical record.

CMS Manual System, Pub 100-04, Medicare Claims Processing Manual, Chapter 32, Section 140.2 states 'As specified at 42 CFR 410.49, Medicare covers cardiac rehabilitation items and services for patients who have experienced one or more of the following'

  • Acute myocardial infarction within the preceding 12 months
  • Coronary artery bypass surgery
  • Current stable angina pectoris
  • Heart valve repair or replacement
  • Percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting
  • Heart or heart-lung transplant

How to Avoid a Denial

  • Submit the information required for coverage when responding to the ADR request

For more information, refer to:

  • CMS Internet-Only Manuals (IOMs), Publication 100-04, Medicare Claims Processing Manual, Chapter 32, Section 140.2
  • Change Request 6850
  • CMS Medicare Learning Network (MLN) Matters article MM 6850 (Cardiac Rehabilitation and Intensive Cardiac Rehabilitation

Denial Code 56900 - (3.5 percent)

  • Reason for Denial
    • The medical records were not received in response to an ADR in the required time frame; therefore, we were unable to determine medical necessity
  • How to Avoid a Denial
    • Monitor your claim status on Direct Data Entry (DDE). If the claim is in status/location SB6001, the claim has been selected for review and records must be submitted. Note: Records may be requested by the Medical Review department, the Claims department, Unified Program Integrity Contractors (UPIC), etc. Ensure the records are submitted to the appropriate entity.
    • Alert your mail staff to be aware of any mail you receive from CGS
    • Be aware of the need to submit medical records within 30 days of the date on the ADR in the upper left corner
    • 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 responding to multiple ADR's, 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 can not accept them
    • Return the medical records to the address indicated in the ADR. Be sure to include the appropriate mail code.

Denial Code 5H169 - (1.1 percent)

Reason for Denial

This claim was partially or fully denied because the provider billed for services/items not documented in the medical record submitted.

How to Avoid a Denial

  • Submit all documentation related to the services billed
  • Ensure that results submitted are for the date of service billed, the correct beneficiary and the specific service billed

For more information, refer to:

  • Code of Federal Regulations, 42 CFR - Sections 410.32 and 424.5

For provider outreach and education opportunities please visit:

For education requests, please submit an Education Request FormPDF.

Providers who receive an Additional Documentation Request (ADR) must submit the requested medical record information within 30 days to:

CGS
J15 Part A Medical Review
Mail Code: AG-735
P.O. Box 100140
Columbia, SC 29202-3140

Please mail the medical records to the following address if you are using FedEx or UPS overnight service:

CGS
J15 Part A Medical Review
Mail Code: AG-735
2300 Springdale Drive, Building One
Camden, SC 29020

Or fax to (803) 462-2596 (Use the ADR letter as a cover sheet).

Providers should ensure the accuracy of their billing and send the following documentation when responding to the ADRs:

  • Physician's orders for all services billed
  • UB-04
  • Any documentation that supports medical necessity for continuous ECG monitoring
  • Documentation that the physician was immediately available for each ECG monitored session billed
  • Nurse's notes
  • Progress notes
  • Lab reports
  • Xray reports (if applicable)
  • Radiology test results
  • Therapy notes (if applicable)
  • Any other diagnostic reports
  • Itemized supply or medication lists for all items billed for these dates of service
  • Please submit all documentation as required in the LCD or NCD (if applicable)
  • If you question the legibility of your signature, you may submit a signature log or an attestation statement in your ADR response. Medicare requires that medical record entries for services provided/ordered be authenticated by the author. The method used shall be a handwritten or an electronic signature. Stamp signatures are not acceptable. Patient identification, date of service and provider of the service should be clearly identified on the submitted documentation.
  • Please submit a copy of an advanced beneficiary notice (ABN) if issued

Completed review results will be posted at www.cgsmedicare.com/parta. Individual providers with significant denials will be contacted for one-on-one education.

Questions regarding this review may be directed to the Medical Review department at (803)763-4999.

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