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Jurisdiction 11 Part A
Continuation of Outpatient Service-Specific Complex Review of Cardiac Rehabilitation without Continuous ECG (HCPCS Code 93797) in North Carolina

The J11 Medical Review department performed a service-specific complex review on claims with outpatient cardiac rehabilitation without continuous ECG (CPT Code 93797) in North Carolina. Of the 73 claims reviewed, 54 were either completely or partially denied. That resulted in a denial rate of 59 percent.

The top four denial reasons identified were:

Percent of Total Denials Denial Code Denial Description
62% 5H261 Cardiac Rehab Sessions Did Not Include the Required Services
18% 5D169/5H169 Services Not Documented
11% 5D301/5H301 Physician Must Be Readily Available
4% 5H241 Cardiac Rehab Not Warranted for Diagnosis

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