May 6, 2016
Urinary Stent Placement (HCPCS Code 52332): Complex Review – Kentucky and Ohio - Continue
The J15 Part A Medical Review department performed a service-specific complex review of claims for Urinary Stent Placement (HCPCS Code 52332) in Kentucky and Ohio from December 2015 through February 2016. Based on the results summarized below, the complex edit review will be continued in Kentucky and Ohio.
Kentucky Complex Edit Results: Urinary Stent Placement (HCPCS Code 52332)
Charges | Claims | |
---|---|---|
Reviewed | $821,927.59 | 215 |
Denied | $217,689.65 | 65 |
Charge Denial Rate | 26.5% |
Ohio Complex Edit Results: Urinary Stent Placement (HCPCS Code 52332)
Charges | Claims | |
---|---|---|
Reviewed | $2,045,542.75 | 404 |
Denied | $610,431.24 | 109 |
Charge Denial Rate | 29.8% |
The top denial reasons associated with this review are:
Denial Code 5D164/5H164 – No documentation of medical necessity
Reason for denial:
- This claim was fully or partially denied because the documentation submitted for review did not support the medical necessity of some of the services billed.
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.
- Use the most appropriate ICD-109-CM codes to identify the beneficiary's medical diagnosis.
For more information, refer to:
- CMS Medicare Program Integrity Manual (Pub. 100-08), Chapter 3, Section 3.3.2.4
- CMS MLN Matters Article MM6698, Signature Guidelines for Medical Review Purposes
- Definition of "medically necessary": Social Security Act (SSA), Section 1862 (a)(1)(A)
- Code of Federal Regulations: 42 CFR 410.32
5C199 – Billing Error
Reason for denial:
- The services billed were not covered. According to documentation in the medical record, the hospital has billed items and/or services in error. The hospital may not charge the beneficiary for items and/or services that were billed in error.
How to prevent denials:
- Check all claims for accuracy prior to submitting to Medicare.
- Ensure that the documentation submitted in response to the ADR corresponds with the date that the service/diagnostic test was rendered and the dates of service billed.
Denial Code 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). 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 Zone Program Integrity Contractor (ZPIC), may also request records. Ensure the records are submitted to the appropriate entity.
- Alert your mail room staff to route any mail you receive from CGS to the appropriate department for handling.
- Submit medical records as soon as the ADR is received, but no later than 45 days of the date on the ADR letter (located in the upper left corner).
- Gather all information needed for the claim and submit it all at one time.
- Attach a copy of the ADR letter to each individual claim.
- If responding to multiple ADRs, separate each response and attach a copy of the ADR letter 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 C.O.D.; we cannot accept them.
- Return the medical records to the address indicated in the ADR letter.
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.