Widespread Targeted Review Results – AL - Part A – 1st Quarter Results of 100% Review of Inpatient Rehabilitation Facilities (IRF) and Inpatient Rehabilitation Units (IRU) including Bill Type 11X, Revenue Code 0024, CMGs A0801-A0802 (replacement of lower extremity joint); Edit Reason Code 5111K
Educational Notification to Medicare IRFs/IRUs of the results of the 1st quarter widespread review of the billing of CMGs A0801-A0802.
Alabama Medical Review Part A has recently completed the 4th quarter widespread targeted prepay review of claims for inpatient rehabilitative services following lower extremity joint replacement processed between January 1, 2007 and March 31, 2007. Educational articles providing the results of previous reviews and guidelines for IRF/IRU services were posted on What’s New May 2006, August 2006 and October 2006, February 2007. These articles may be found on the What's New from Cahaba page. The results of the current review are as follows:
1st Quarter 2007:
Providers Reviewed: 59
Claims Reviewed: 244
Claims Approved: 28
Claims Denied: 216
Charges Reviewed: $ 2,806,585.33
Charges Approved: $ 373,808.11
Charges Denied: $ 2,432,777.22
Error Rate: 87%*
* error rate is based on the charges denied divided by the charges reviewed
As with previous reviews, the majority of denials of IRF/IRU claims reviewed resulted from the information submitted did not provide the medical justification for the IRF/IRU services indicated by denial reason code 54155. The medical review of inpatient rehabilitative treatment of lower extremity joint replacement decisions were based on the Local Coverage Determination (LCD) L15198- Inpatient Rehabilitation, which outlines specific documentation requirements to support the medical necessity for all Inpatient Rehabilitation admissions.
The LCD may be found on the Active LCDs page.
Additionally, 18 claims were denied due to a lack of record submission in a timely manner, resulting in a 56900 denial. According to Medicare Program Integrity Manual, PUB 100-8, Chapter 3, § 3.4.1.2, if a coverage or coding determination cannot be made based upon the information on the claim, the Fiscal Intermediary (FI) may solicit additional documentation from the provider by issuing an Additional Documentation Request (ADR) and must notify the provider of the 30 day time-period to respond. The ADR requested information is not is received within 45 days after the date of the request, then the claim must be denied.
To eliminate 56900 denials, please review the following elements to ensure appropriate and timely record processing:
- Beginning January 1, 2007, Cahaba will no longer send letters to inform providers of Additional Development Requests (ADRs). Instead, providers will need to access the Fiscal Intermediary Standard System (FISS) to identify claims selected for ADR. Claims selected for ADR can be identified by accessing FISS Inquiry Option 12, and will appear in status location S B6001. Pages 07 and 08 of the claim will contain the date your documentation is due, and the elements of documentation requested.
- Attach a copy of the ADR to the front of the requested medical documentation
- Send requested information to the address on the ADR letter
- Do NOT send certified mail or overnight mail
- Include ALL requested documentation outlined in the ADR
- Submit the above information via regular mail in a timeframe to ensure the FI receives the information by the 45th day after the date of the request.
Cahaba Alabama Medical Review Part A again reminds the provider community of the importance of thorough documentation in the medical record to support CMS requirements for IRF services and timely submission of requested claims documentation.
Cahaba Alabama Medical Review Part A will continue the 100% widespread targeted pre-pay review of all IRFs and IRUs (Bill Type 11X) with revenue code 0024 (all inclusive ancillary) billing CMG A0801 (replacement of lower extremity joint with motor score from 58-84 without co-morbid conditions) and CMG A0802 (replacement of lower extremity joint with motor score from 55-57 without co-morbid conditions). This review will be identified by edit reason code 5111K.
In addition to the previously mentioned references, IRFs and IRUs billing for inpatient rehabilitation services should review Medicare Benefit Policy Manual PUB 100-2, Chapter 1, §110, and Medicare Claims Processing Manual PUB 100-4, Chapter 3, §140 to ensure adherence to all coverage criteria. Additional information regarding Inpatient Rehabilitation services may be found in the Federal Register, Volume 69, Number 89/ Friday, May 7, 2004, pages 25762-25763 and the United States Government Accountability Office (GAO) Report, April 2005.
Page last updated: April 24, 2007
