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

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CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CGS or the CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

CMS Disclaimer

The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

This license will terminate upon notice to you if you violate the terms of this license. The AMA is a third party beneficiary to this license.

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

End User License Agreement

These materials contain Current Dental Terminology, Fourth Edition (CDT), copyright © 2002, 2004 American Dental Association (ADA). All rights reserved. CDT is a trademark of the ADA.

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  1. Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT-4 only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT-4 is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT-4. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.
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February 28, 2017

Cardiac Rehabilitation (HCPCS Code 93798): Complex Medical Review – Kentucky and Ohio – Continued

The J15 Part A Medical Review department performed a service-specific complex review of claims for Cardiac Rehabilitation (HCPCS Code 93798) in Kentucky and Ohio from October through December 2016. Based on the results summarized below, the complex edit review will be continued in Kentucky and Ohio.

Kentucky Service-Specific Complex Edit Results:

  Charges Claims
Reviewed $1,682,317.21 123
Denied $937,072.28 67
Charge Denial Rate 55.7%  

Ohio Service-Specific Complex Edit Results:

  Charges Claims
Reviewed $5,339,379.38 432
Denied $2,496,506.34 227
Charge Denial Rate 46.8%  

The top denial reasons associated with this review are:

5D261 – Sessions did not inlcude 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
  • 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.
    • CGS published an article, "Cardiac Rehabilitation: Coverage and Documentation Requirements," which defines the required documentation for each of these elements of cardiac rehabilitation.

For more information, refer to:

5D301 – Physician must be readily available

  • Reason for denial:
    • This claim was partially or fully denied because the documentation did not support that the program was under the direct supervision of a physician.
  • How to prevent denials:
  • Submit all documentation related to the services billed when responding to the Additional Documentation Request (ADR).
  • CGS published an article, "Cardiac Rehabilitation: Coverage and Documentation Requirements" which defines physician supervision requirements in hospital-based and non-hospital-based settings and provides other important guidance regarding documentation and claim submission.
  • Upon request, submit the required information based on the setting:
    • The patient's medical record must clearly identify the service as hospital-based or non-hospital-based.
    • The requirements differ by setting. Refer to the CGS web article for additional information.

For more information, refer to:

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). Claims in status/location SB6001 have 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.
    • Ensure your mail room staff is aware of any mail you receive from CGS.
    • Ensure medical records are submitted within 45 days of the date in the upper left corner of the ADR letter.
    • 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. Be sure to include the appropriate mail code.

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.

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