Medical Review


Resumption of Postpayment Medical Reviews
As recently published at MACs Resume Medical Review on a Postpayment Basis, Medicare Administrative Contractors (MACs) resumed fee-for-service medical review activities to protect the Medicare Trust Fund against inappropriate payments. Effective September 1, 2021, the MACs will discontinue sending postpayment additional documentation requests (ADR) and will resume reviews  conducted under the Targeted Probe and Educate (TPE) Medical Review Strategy.  Providers should continue responding to Postpayment ADR requests already issued. Please continue to refer to information outlined in Receiving and Responding to a Palmetto GBA Additional Documentation Request (ADR) for Postpayment Review. For more information on TPE please visit Targeted Probe and Educate.  

Medical review is the collection of information and clinical review of medical records by Palmetto GBA to ensure that payment is made only for services that meet all Medicare coverage, coding and medical necessity requirements. Medical review activities are directed toward areas where data analyses indicate questionable billing patterns.

The goal of the medical review program is to reduce payment errors by identifying and addressing billing errors made by providers concerning coverage and coding. To achieve the goal of the medical review program, Palmetto GBA:

  • Proactively identifies patterns of potential billing errors concerning Medicare coverage and coding made by providers through data analysis and evaluation of other information (e.g., complaints);
  • Reviews data analysis reports;
  • Takes action to prevent and/or address the identified error;
  • Publishes local medical review policies via Local Coverage Determinations (LCDs) to provide guidance to the public and medical community about when items and services will be eligible for payment under the Medicare statute

Additional Resources





Medical Review Articles


5D169 - Services Not Documented53NCD - NCD Denial - No Diagnosis/Documentation to Support Medical Necessity (Provider Liable) (Beneficiary Liable)5D507 - SNF MDS Is Not in the National Repository5D002 - Agree With Provider (Beneficiary Liable)5H169 - Services Not Documented5D161 - No Physician's Orders56900 - Auto Denial - Requested Records Not Submitted5J504 - Need For Services Not Medically and Reasonable Necessary5D920 - The Recommended Protocol Was Not Ordered and/or Followed5D510 - There Was No Evidence of at Least Three Consecutive Day of Inpatient Hospital Stay5H507 - SNF MDS Is Not in the National Repository5D165 - The Documentation Submitted Did Not Include the Required Certifications or Recertification5H164 - Documentation Does Not Support Medical Necessity54NCD - NCD Denial - No Diagnosis/Documentation to Support Medical Necessity (Provider Liable) (Beneficiary Liable)5H151 - Units Billed More than Ordered5D164 - Documentation Does Not Support Medical Necessity5D501 - Billed in Error5H165 - The Documentation Submitted Did Not Include the Required Certifications or Recertification5CHGE - DRG Upcode/Downcode5H161 - No Physician's Orders5H501 - Billed in Error5J502 - Information Submitted Does Not Support Dates BilledTargeted Probe and Educate Progress Update: DRG 885 - Psychoses5D700 - No Valid Plan of Treatment PresentTargeted Probe and Educate Progress Update: DRG 682/683 - Renal FailureTargeted Probe and Educate Progress Update: JJ Part A Infliximab J1745Targeted Probe and Educate Progress Update: Therapeutic Exercise 971105D650 - No Valid Certification/Recertification Present5D162 - Provider Did Not Submit All Records RequestedMedical Review Administrative Relief Related to the Novel Coronavirus (COVID-19) PandemicTargeted Probe and Educate Progress Update: JJ Part A Denosumab J0897Targeted Probe & Educate (TPE) Provider Contact5D503 - Not Medically Reasonable and NecessaryTargeted Probe and Educate Progress Update: JJ DRG 470 - Major Joint ReplacementTargeted Probe and Educate Progress Update: JJ Part A Manual Therapy - 97140Targeted Probe and Educate Progress Update: JJ Part A - Pegfilgrastim J25055D800 - Inpatient Psychiatric Services Not Medically Necessary5DOWN - Medical Review DowncodeTargeted Probe and Educate Progress Update: JJ Part A Rituximab J9310Targeted Probe and Educate Progress Update: JJ Part A Bevacizumab J90355H504 - Not Medically Reasonable and NecessaryTargeted Probe and Educate Progress Update: JJ Part A Inpatient Rehabilitation Facility (IRF) A0604-D0604Targeted Probe and Educate VideoTargeted Probe and Educate Progress Update: DRG 291 - Heart Failure and Shock with MCC and DRG 292 - Heart Failure with CC5D504 - Not Medically Reasonable and Necessary5H162 - Provider Did Not Submit All Records RequestedTargeted Probe and Educate Progress Update: HBO Therapy G0277Targeted Probe and Educate Progress Update: JJ Part A Skilled Nursing Facility (SNF)Medical Review Intent to Reopen Process for Non-Receipt of Medical Record DenialsHyperbaric Oxygen ChecklistPalmetto GBA Partnering with Providers to Get it Right the First TimeOutpatient Therapy (OT) Exercises ChecklistActive Service Specific Postpayment Medical ReviewsOutpatient Hospital Department (OPD) Prior Authorization (PA) Fax NumberOutpatient Department (OPD) Prior Authorization (PA) Required DocumentationOutpatient Department (OPD) Prior Authorizations (PA)Outpatient Department Prior Authorization CalculatorOutpatient Department (OPD) Prior Authorization (PA) Alert!Prior Authorization Process for Certain Hospital Outpatient Department (OPD) Services Frequently Asked QuestionsPrior Authorization for Certain Hospital Outpatient Department (OPD) Services TerminologyBlepharoplasty and Blepharoptosis RepairOutpatient Department Prior Authorization (OPD) eServices Submission GuideOutpatient Department (OPD) Prior Authorization (PA) Part 1 Program OverviewOutpatient Department (OPD) Prior Authorization (PA) ExemptionDiagnosis Related Group (DRG 470) Reason Code CrosswalkDiagnosis Related Group (DRG) 885 ChecklistNeulasta Reason Code CrosswalkDiagnosis Related Group (DRG) 885 Reason Code CrosswalkDrugs and Biologicals DenialsCharge Denial Rate (CDR) CalculatorOutpatient Therapy: Denial Reason Code CrosswalkDiagnosis Related Group (DRG) 470 ChecklistDiagnosis Related Group (DRG) Coding ChecklistRituxan Reason Code CrosswalkHyperbaric Oxygen Reason Code CrosswalkAvastin - Denial Reason CrosswalkRemicade Reason Code CrosswalkDenosumab (Prolia) J0897 Reason Code CrosswalkDRG 470 - Major Joint Replacements or Reattachment of Lower ExtremityMedical Review Part A Fact SheetVein Ablation and Related ServicesThe Prior Authorization (PA) Program for Certain Hospital Outpatient Department (OPD) Services Operational GuideComplying with Medicare Signature RequirementsMedical Review Program and Targeted Probe and Educate HandoutTargeted Probe and Educate Process ModuleAccess TPE Letters Electronically Job AidesMD for the Review Choice Demonstration (RCD) and the Outpatient Department (OPD) Prior Authorization (PA)Medicare Record Authentication: Tips for PhysiciansOutpatient Rehab Therapeutic Exercise Postpayment Results for October to December 2020Botulinum Toxin InjectionsOutpatient Department (OPD) Prior Authorization (PA)ADRs for Outpatient Department Prior Authorization services (OPD PA) ServicesPanniculectomyPostpayment Service-Specific Probe Results for Bevacizumab 10mg for January through March 2021Postpayment Service-Specific Probe Results for Outpatient Hyperbaric Oxygen for January through March 2021Postpayment Service-Specific Probe Results for Pegfilgrastim (Neulasta) for January through March 2021Postpayment Service-Specific Probe Results for Denosumab (Prolia) for January through March 2021CMS MLN Fact Sheet: Medical Record Maintenance and Access RequirementsOutpatient Prior Authorization (OPA) Status ToolMACs Resume Medical Review on a Postpayment BasisSpinal Cord Stimulator ChecklistCervical Discectomy ChecklistPostpayment Service-Specific Probe Review for Outpatient Rehabilitation Services, Therapeutic Exercises for January through March 2021Receiving and Responding to a Palmetto GBA Additional Documentation Request (ADR) for Postpayment ReviewCervical Disc Spinal Fusion and Spinal Cord Stimulator On-Demand WebcastVein Ablation and Related ServicesHospital Outpatient Department (OPD) Prior Authorization Exemption ProcessReason Code 5OP64: Date for the Item or Service That Is Subject to Prior Authorization Is After the Expiration Decision DateReason Code 5OP70: Service Is Subject to Prior Authorization and No UTN Is Present on the ClaimReason Code 5OP69: Service Is Subject to Prior Authorization and No UTN Is Present on the ClaimReason Code 5OP68: Service Is Subject to Prior Authorization and No UTN Is Present on the ClaimReason Code 5OP62: Item of Service Is Subject to Prior Authorization and No Prior Authorization Was Requested for the Item of ServiceReason Code 55503: Line Denied Medical Necessity Was Not Supported as Outlined in Palmetto GBA's LCD CoverageReason Code 55504: Line Denied Medical Necessity Was Not Supported as Outlined in Palmetto GBA's Local Coverage DeterminationReason Code 5DTDP: Dependent Services Denied (Qualifying Service Denied Technically)Reason Code 5J503: No Orders for Inpatient AdmissionReason Code 5D199: Billing ErrorReason Code 5DMDP: Dependent Services Denied (Qualifying Service Denied Medically)Reason Code 5H920: The Recommended Protocol Was Not Ordered and/or FollowedReason Code 5HDMP: Dependent Services Denied (Qualifying Service Denied Medically)Reason Code 52NCD: NCD Denial: HCPCS, Diagnosis Matched National Coverage Determination (NCD) Table List ICD9-CM Deny CodesReason Code 5H920: The Recommended Protocol Was Not Ordered and/or FollowedReason Code 5HTDP: Dependent Services Denied (Qualifying Service Denied Technically)Reason Code 5HMDP: Dependent Services Denied (Qualifying Service Denied Medically)Reason Code 5X002: Agree with Provider (Beneficiary Liable)Reason Code 5H199: Billing ErrorReason Code 5D011: Agree with Provider (Provider Liable)Postpayment Service-Specific Probe Results for Prolia (Denosumab) for April through June 2021Postpayment Service-Specific Probe Results for Keytruda (Pembrolizumab) for April through June 2021Postpayment Service-Specific Probe Results for Neulasta (Pegfilgrastim) for April through June 2021Postpayment Service-Specific Probe Results for Keytruda (Pembrolizumab)for April through June 2021Postpayment Service-Specific Probe Results for Therapeutic Exercise for April through June 2021Postpayment Service-Specific Probe Results for DRG 885: Psychoses for April through June 2021Postpayment Service-Specific Probe Results for Outpatient Hyperbaric Oxygen for April through June 2021JJ Part A and Part B Targeted Probe and Educate (TPE) Active Medical Review ListClaim Selection Process for Targeted Probe and Educate: S B6000 vs. S B6001How to Check Your Outpatient Department Prior Authorization (OPD) Results StatusTargeted Probe and Educate Resumed September 1, 2021Medicare Medical Records: Signature Requirements, Acceptable and Unacceptable PracticesPostpayment Service-Specific Probe Results for Bevacizumab (Avastin) for April through June 2021RhinoplastyOPEN: Some Outpatient Department Prior Authorization Claims (OPA) are Editing for Reason Code 39621 IncorrectlyPostpayment Service-Specific Probe Results for Outpatient Rehabilitation Services: Manual Therapy for January through March 2021Implantation of Spinal Neurostimulator