Update from Palmetto regarding Pulmonary rehab audits

Palmetto GBA Outpatient Pulmonary Rehab – G0424
The Jurisdiction 11 Part A Medical Review Department has performed a second round of prepayment service specific probe reviews on Outpatient Pulmonary Rehab – G0424. The error rate for the first round of prepayment reviews was 87.9 percent and the second review error rate was at 76 percent. A total of 342 claims were reviewed, with 287 of claims either completely or partially denied. The total dollars reviewed was $359,466 out of which $273,146 was denied. The top denial reasons identified were:

  • Denial Code 5D901/5H901 – Pulmonary Rehab Not Warranted for Diagnosis – 38.8%
  • Denial Code 5D902/5H902 – Documentation Did Not Include the Required Components – 20.7%
  • Denial Code 5D169/5H169 – Services Not Documented – 15.4%
  • Denial Code 5D404/5H404 – No Order/Referral for Pulmonary Rehabilitative Services – 15.1%
  • Denial Code 5D903/5H903 – Physician Must Be Readily Available – 5.5%
  • Denial Code 56900 – Requested Medical Records Not Submitted Timely – 4.4%

The complete report expands on each of the denial reason codes above and offers guidance on how to avoid these denials in the future. The service specific targeted medical review edits for HCPCS code G0424 will continue as this is considered a major risk. The link to the complete report is available at: http://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Jurisdiction%2011%20Part%20A~Medical%20Review~Results~Completion%20of%20Prepayment%20Service-Specific%20Targeted%20Medical%20Review%20Outpatient%20Pulmonary%20Rehab%20(HCPCS%20Code%20G0424).