November 4, 2013
Cardiac Rehabilitation (CPT Code 93798): Complex Medical Review, Kentucky – Discontinue Complex Review
The J15 Part A Medical Review department performed a service-specific complex review of Cardiac Rehabilitation with Continuous ECG Monitoring (CPT code 93798), type of bill (TOB) 13X, for Kentucky. Based on the results summarized below, the review will be discontinued.
Charges | Claims | |
---|---|---|
Reviewed | $371,195.11 | 261 |
Denied | $106,797.79 | 89 |
Charge Denial Rate | 28.8% |
The top three denial reasons associated with this review are:
5D261/5H261 – Sessions Did Not Include 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
- 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:
- How to prevent denials:
- CGS published an article, "Cardiac Rehabilitation: Coverage and Documentation Requirements," which defines the required documentation for each of these elements of cardiac rehabilitation.
- We strongly recommend you review this article in its entirety.
- Upon request, provide supporting documentation for all required elements.
For more information, refer to:
- CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 32, section 140.2
- CMS MLN Matters article MM6850: "Cardiac Rehabilitation and Intensive Cardiac Rehabilitation"
- CGS web article, "Cardiac Rehabilitation: Coverage and Documentation Requirements"
5D169/5H169 - Services Not Documented
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 prevent denials:
- 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:
Individual providers with significant denials will be contacted for one-on-one education.
If you have questions regarding this review, please contact the Medical Review department at 803.763.4999.