Prepayment Service-Specific Targeted Medical Review Results for Part A Outpatient Pulmonary Rehab (HCPCS code G0424) for North Carolina, South Carolina and Virginia
Palmetto GBA performed service-specific prepayment targeted medical review on Part A claims for HCPCS code G0424, Outpatient Pulmonary Rehab, in North Carolina, South Carolina and Virginia. The review period was May 1, 2013, through July 31, 2013, and the results of the targeted medical review are presented below:
North Carolina
A total of 160 claims were reviewed, with 131 of the claims either completely or partially denied. The total dollars reviewed was $172,108.62 out of which $129,982.83 was denied, resulting in a charge denial rate of 75.5 percent. The denial reasons identified were:
|
Percent of Total Denials
|
Denial Code
|
Denial Description
|
|---|---|---|
|
28.5%
|
5D901
|
Pulmonary Rehab Not Warranted For Diagnosis
|
|
27.2%
|
5D902/5H902
|
Documentation Did Not Include the Required Components
|
|
13.4%
|
5D404/5H404
|
No Order/Referral for Pulmonary Rehabilitative Services
|
|
11.7%
|
5D169/5H169
|
Services Not Documented
|
|
10.6%
|
5D903/5H903
|
Physician Must Be Readily Available
|
|
8.6%
|
56900
|
Auto Denial – Requested Medical Records Not Submitted
|
South Carolina
A total of 58 claims were reviewed, with 51 of the claims either completely or partially denied. The total dollars reviewed was $51,493.92 out of which $46,264.92 was denied, resulting in a charge denial rate of 89.9 percent. The denial reasons identified were:
|
Percent of Total Denials
|
Denial Code
|
Denial Description
|
|---|---|---|
|
34.8%
|
56900
|
Auto Denial – Requested Medical Records Not Submitted
|
|
25.8%
|
5D903
|
Physician Must Be Readily Available
|
|
18.2%
|
5D169/5H169
|
Services Not Documented
|
|
9.1%
|
5D902
|
Documentation Did Not Include the Required Components
|
|
6.0%
|
5D404
|
No Order/Referral for Pulmonary Rehabilitative Services
|
|
6.0%
|
5D901
|
Pulmonary Rehab Not Warranted For Diagnosis
|
Virginia
A total of 112 claims were reviewed, with 96 of the claims either completely or partially denied. The total dollars reviewed was $148,213.62 out of which $135,648.33 was denied, resulting in a charge denial rate of 91.5 percent. The denial reasons identified were:
|
Percent of Total Denials
|
Denial Code
|
Denial Description
|
|---|---|---|
|
61.9%
|
56900
|
Auto Denial – Requested Medical Records Not Submitted
|
|
11.3%
|
5D169/5H169
|
Services Not Documented
|
|
10.5%
|
5D902/5H902
|
Documentation Did Not Include the Required Components
|
|
6.1%
|
5D901
|
Pulmonary Rehab Not Warranted For Diagnosis
|
|
6.0%
|
5D903
|
Physician Must Be Readily Available
|
|
4.3%
|
5D404/5H404
|
No Order/Referral for Pulmonary Rehabilitative Services
|
Denial Reasons and Prevention Recommendations
56900 – Auto Denial – Requested Medical Records Not Submitted
Reason for Denial
The services billed were not covered because the claim was not submitted or not submitted timely in response to an Additional Development Request (ADR). When an ADR is generated, the provider has 30 days from the date the ADR was generated to respond with medical records. In accordance with CMS instructions, if the documentation needed to make a medical review determination is not received within 45 days from the date of the documentation request, Palmetto GBA will make a medical review determination based on the available medical documentation. If the claim is denied, payment will be denied or an overpayment will be collected.
How to Avoid a Denial
- Be aware of the ADR date and the need to submit medical records within 30 days of the ADR date
- Submit the medical records as soon as the ADR is received
- Monitor the status of your claims in Direct Data Entry (DDE) and begin gathering the medical records as soon as the claim goes to the location of SB6001
- Return the medical records to the address on the ADR. Be sure to include the appropriate mail code or station number. This ensures that your responses are promptly routed to the Medical Review Department.
- Gather all of the information needed for the claim and submit it all at one time
- Attach a copy of the ADR request to each individual claim
- If responding to multiple ADRs, separate each response and attach a copy of the ADR to each individual set of medical records. Make sure each set of medical records is bound securely with one staple in the upper left corner or a rubber band to ensure that no documentation is detached or lost. Do NOT use paper clips.
- Do not mail packages C.O.D.; we cannot accept them
For more information, refer to the following articles our website titled ‘Medical Review Progressive Corrective Action (PCA) Process’.
5D902/5H902- Documentation did not Include Required Components
Reason for Denial
This claim was fully denied because the following components of the pulmonary rehabilitation program were not submitted in the medical record:
- Physician-prescribed exercise
- Education or training
- 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 140.4
- Change Request 6823
- CMS Medicare Learning Network (MLN) Matters article MM6823 (Pulmonary Rehabilitation Services)
5D903/5H903 – Physician must be readily available
Reason for Denial
The claim was denied because the requirement for pulmonary 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 100-04, Medicare Claims Processing Manual, Chapter 32, Section 140.4
- Code of Federal Regulations, 42 CFR – Section 410.32 (b)(3)(ii)
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 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 more information, refer to the following articles our website titled Responding to an Outpatient Therapy Additional Development Request’
5D901/5H901 – Pulmonary Rehab Not Warranted for Diagnosis
Reason for Denial
The claim was fully denied because the condition required for coverage of pulmonary rehabilitation services was not submitted in the medical record.
- CMS Manual System, Pub 100-04, Medicare Claims Processing Manual, Chapter 32, Section 140.4 states “As specified in 42 CFR 410.47, Medicare covers pulmonary rehabilitation items and services for patients with moderate to very severe COPD (defined as GOLD classification II, III, and IV), when referred by the physician treating the chronic respiratory disease.
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 140.4
5D404/5H404 – No Orders/Referrals for Pulmonary Rehabilitative Services
Reason for Denial
The services billed were not covered due to no physician’s order or referral for pulmonary rehabilitative services.
How to Avoid a Denial
In order to avoid unnecessary denials for this reason, the provider should ensure that the physician’s orders/referrals cover the services to be billed prior to billing Medicare. When responding to an Additional Documentation Request (ADR), ensure that all orders/referrals for services billed are included with the medical records. The Medicare program requires that the physician order/referral is set up for furnishing services.
For further information on the above Medicare coverage issue, references include, but are not limited to, these resources:
- 42 CFR 410.47 Pulmonary Rehabilitation Program: Conditions for Coverage
- Medicare Claims Processing Manual Chapter 32 – Billing Requirements for Special Services
The Next Steps
The service-specific targeted medical review edits for Part A Outpatient Pulmonary Rehab, HCPCS G0424 will be continued in North Carolina, South Carolina and Virginia. This service has been identified as a major risk area for J11, and the review results show a high charge denial rate and high severity impact errors in each state. If significant billing aberrancies are identified, provider-specific review may be initiated.