License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

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POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

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August 6, 2013

Medical Back Problems without Major Complication or Comorbidity (MCC)((Diagnosis Related Group (DRG) 552): Results of Complex Medical Review, Ohio

The J15 Part A Medical Review department performed a service-specific complex review on Medical Back Problems without MCC in Ohio from February through April 2013. Based on the results summarized below, the complex edit review will continue in Ohio.

**Ohio Service-specific Complex Edit Results: Medical Back Problems without MCC, DRG 552**
	Charges	Claims
Reviewed	$170,723.56	40
Denied	$128,648.80	30
Charge Denial Rate	75.4%

The top denial reasons associated with this review are:

Denial Code 5J504 - Need for Service/Item Not Medically and Reasonably Necessary (93.46 percent of dollars denied)

Reason for denial:
- The documentation submitted for review did not support the medical necessity of the services provided
How to prevent denials:
- Documentation and tips that may be helpful to avoid future denials for this reason may include, but are not limited to the following:
  - Submit documentation to support that all services were medically necessary on an inpatient basis instead of a less intensive setting
  - Documentation should include all clinical information for the dates of service billed such as physician progress notes, physical examinations, assessments, diagnostic tests and laboratory test results, history and physical, nurse's notes, consultations, surgical procedures, orders and discharge summary and any other documentation to support the inpatient admission
  - Include documentation of services, medication and medical interventions performed in the Emergency department.
  - For elective surgical procedures, include documentation to support the necessity of the procedure including pre-surgical interventions and outcomes.
For more information, refer to:
- Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Medicare Program Integrity Manual (Publication 100-08), Chapter 6, Section 6.5
- CMS Medicare Benefit Policy Manual (Publication 100-02), Chapter 1, Sections 1 and 10
- CMS Medicare Learning Network (MLN) Matters article SE 1037 - Guidance on Hospital Inpatient Admission Decisions

Denial Code 56900 - Requested Records Not Submitted (2.44 percent of dollars denied)

Reason for denial:
- The medical records were not received in response to an Additional Documentation Request (ADR) in the required time frame; therefore, we were unable to determine medical necessity
How to prevent denials:
- 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. Please note: CGS may request records through our Medical Review or Claims departments, and other contractors such as the Unified Program Integrity Contractor (UPIC) may also request records. Ensure the records are submitted to the appropriate entity.
- Alert your mail room 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 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

If you receive a request for medical records, please submit the following information within 30 days to the address on the ADR:

Physician's orders for the admission and all services billed
Itemized list of charges
Hospital admission assessment and hospital discharge summary
Hospital history and physical
Physician progress notes
Consultation reports
Plan of care
Diagnostic test results/reports, including imaging reports
Clinical/therapy notes
Please submit all documentation to support the medical necessity of services billed and the DRG code billed
A signature log or an attestation statement, if you question the legibility of your signature. Medicare requires that medical records entries for services provided/ordered be authenticated by the author. The signature may be handwritten or electronic; stamp signatures are not acceptable. Patient identification, date of service, and provider of the service should be clearly identified on the submitted documentation.
- If the signature requirements are not met, we will conduct the review without considering the documentation with the missing or illegible signature. This may lead us to determine that the medical necessity for the service billed has not been substantiated.
- For more information regarding signature requirements for Medicare purposes, refer to the CMS Medicare Program Integrity Manual (Pub. 100-08), Chapter 3, Section 3.3.2.4and CMS MLN Matters article MM6698, "Signature Requirements for Medical Review Purposes".

Options for Submitting Records

You may submit medical records compact discs (CDs) or digital video discs (DVDs) to CGS. You must use the correct file format of tagged image file format (tiff), which may be saved to your CD/DVD.
You may also submit records via fax to: (803) 462-2596. Use the ADR letter as a cover sheet.
If you choose to respond by mail, send the requested records to the address indicated in the ADR letter.

Completed review results will be posted on the CGS website. Individual providers with significant denials will be contacted for one-on-one education.

If you have questions regarding this review, please contact the CGS Medical Review department at (803) 763-4999.