Pre-Payment Review Results for DRG 470 Major Joint Replacement for July to September 2024

Published 11/11/2024

Pre-payment Review Results for Diagnosis Related Group (DRG) 470 Major Joint Replacement for Targeted Probe and Educate (TPE) for July to September 2024

The Centers for Medicare & Medicaid Services (CMS) implemented the TPE process for DRG 470 Major Joint Replacement. The reviews with edit effectiveness are presented here for North Carolina, South Carolina, Virginia and West Virginia.

Cumulative Results

Table 1. Cumulative Results.
Number of Providers with Edit Effectiveness Providers Compliant Completed/Removed After Probe Providers Non-Compliant Progressing to Subsequent Probe Providers Non-Compliant/Removed for other Reason
26 24 2 0
Table 2. Cumulative Results.
Number of Claims with Edit Effectiveness Number of Claims Denied Overall Claim Denial Rate Total Dollars Reviewed Total Dollars Denied Overall Charge Denial Rate
348 14 4% $4,624,951.10 $176,994.38 4%

Probe One Findings

Table 3. Probe One Findings.
State Number of Providers with Edit Effectiveness Providers Compliant Completed/Removed After Probe Providers Non-Compliant Progressing to Subsequent Probe Providers Non-Compliant/Removed for Other Reason
N.C. 10 9 1 0
S.C. 5 4 1 0
Va. 9 9 0 0
W.Va. 2 2 0 0
Table 4. Probe One Findings.
State Number of Claims with Edit Effectiveness Number of Claims Denied Overall Claim Denial Rate Total Dollars Reviewed Total Dollars Denied Overall Charge Denial Rate
N.C. 157 5 3% $2,120,977.02 $64,781.62 3%
S.C. 55 4 7% $703,259.06 $53,326.69 8%
Va. 111 5 5% $1,469,615.84 $58,886.07 4%
W.Va. 25 0 0% $331,099.18 $0 0%

Risk Category
The categories for DRG 470 Major Joint Replacement are defined as:

Table 5. Risk Category.
Risk Category Error Rate
Minor 0–20%
Major 21–100%

Fig. 1. Risk Category for DRG 470.
Pie chart showing 100% minor findings

Top Denial Reasons

Table 5. Top Denial Reasons.
Percent of Total Denials Denial Code Denial Description Number of Occurrences
38% 56900 Auto Deny — Requested Records Not Submitted Timely 5
38% 5J504, 5K504 Need for Services Not Medically and Reasonably Necessary 5
15% 5CHG3 Medical Review HIPPS Code Change Due to Partial Denial of Therapy 2
8% 5D199, 5H199 Billing Error 1

Denial Reasons and Recommendations

56900 — Auto Deny — Requested Records Not Submitted Timely

Reason for Denial
The services billed were not covered because the documentation was not received in response to the Additional Documentation Request (ADR) and therefore, we were unable to determine the medical necessity of the service billed. The provider has 45 days from the date the ADR was generated to respond with medical records. If less than 120 days after denial notification on the remittance advice, submit records to the contractor requesting records at the address listed on the original ADR to request reopening. Do not resubmit the claim.

How to Avoid This Denial

  • Be aware of the ADR date and the need to submit medical records within 45 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. Fax and electronic data submissions are also accepted as indicated on the ADR.
  • 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 individually identifiable and bound securely 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

Resources

5J504/5K504 — Need for Services Not Medically and Reasonably Necessary

Reason for Denial
The claim has been fully or partially denied as the documentation submitted for review did not support the services provided were medically reasonable and necessary.

How to Avoid This Denial

Inpatient Hospital Services

  • Documentation should include all clinical information for the dates of service billed such as physician progress notes, physical examinations, assessments, diagnostic tests and laboratory test results, history and physical, nurse’s notes, consultations, surgical procedures, orders and discharge summary and any other documentation to support the inpatient admission
  • Include documentation of services, medication and medical interventions performed in the emergency department
  • For surgical procedures, include documentation to support the necessity of the procedure:
    • Emergent Procedures
      • Diagnostic studies to support the covered indication for the procedure as emergent
    • Non-Emergent (Elective) Procedures
      • Pre-surgical impact on beneficiary that supports the need for the procedure
      • Pre-surgical treatments and outcomes
      • Diagnostic studies to support the covered indication for the procedure

Please also ensure that diagnostic and procedural information and the discharge status of the beneficiary matches both the attending physician's description and the information contained in the beneficiary's medical record.

Resources

Inpatient Rehabilitation Facility (IRF) Services

  • Preadmission Screening (PAS)
    • The IRF should develop a thorough preadmission screening process to ensure the PAS includes all required elements.
      • Ensure that the PAS contains at a minimum the elements outlined below
        • Information about the conditions that caused the patient’s need for IRF services
        • Evaluation for any risk for clinical complications
        • Patient’s prior level of function
        • Expected level of improvement and expected length of time to achieve
        • Expected treatments the patient will require (i.e., physical therapy, occupational therapy, speech-language pathology or prosthetics/orthotics)
        • Patient’s anticipated discharge location
      • Ensure the PAS is completed or updated within 48 hours immediately preceding the IRF admission
      • The PAS was conducted by a licensed or certified clinician(s) designated by a rehabilitation physician, as long as the clinicians are licensed or certified to perform the evaluation
      • The rehabilitation physician concurred with the findings and results of the PAS
        • The rehabilitation physician must be a licensed physician who is determined by the IRF to have specialized training and experience in inpatient rehabilitation
  • Individualized plan of care (POC)
    • The IRF should develop a thorough process to ensure the POC documentation meets at least the requirements as outlined below.
      • Ensure the POC is individualized overall and is completed within four days of admission to the IRF
      • Ensure the POC is developed by the rehabilitation physician with input from the interdisciplinary team
        • The rehabilitation physician must be a licensed physician who is determined by the IRF to have specialized training and experience in inpatient rehabilitation
  • Interdisciplinary Team Meeting (IDT)
    • Meeting notes/documentation must be maintained and support the below requirements were met
      • The IDT meetings are led by a rehabilitation physician
      • The rehabilitation physician must be a licensed physician who is determined by the IRF to have specialized training and experience in inpatient rehabilitation
      • All required participants (rehabilitation physician, rehabilitation registered nurse, social worker and/or case manager, licensed or certified therapist from each therapy discipline) attend the IDT meetings
        • A therapy assistant does not meet the requirement for a certified or registered therapist
        • The IDT meetings are held at a minimum of once per week
        • The IDT meetings address goal progress and/or any problems impeding the goal progress
        • The documentation supports the rehabilitation physician concurs with the results and findings of the IDT meeting
  • Reasonable and Necessary
    • Documentation should support the patient's condition is expected to require supervision by the rehabilitation physician
      • The rehabilitation physician must be a licensed physician who is determined by the IRF to have specialized training and experience in inpatient rehabilitation
      • Documentation should also support the IRF physician saw the patient a minimum of three times per week. Beginning with the second week of the IRF admission, a qualified nonphysician practitioner may conduct one of the three required face-to-face visits per week, if the patient is discharged on or after Oct. 1, 2022.
    • Documentation should support that upon admission to the IRF the patient generally required the intensive rehabilitation therapy services that are uniquely provided in IRFs
    • Documentation should support the patient's medical condition is stable enough for them to be reasonably expected to actively participate in and benefit significantly from the intensive rehabilitation therapy program
    • Documentation should support that upon admission a measurable improvement that will be of practical value was expected in a reasonable period of time
    • Documentation should support intensive rehabilitation services are required and are provided to include the below
      • Documentation should support the patient's condition requires the active and ongoing therapeutic intervention of multiple therapy disciplines (physical therapy, occupational therapy, speech language pathology, or prosthetics/orthotics), one of which must be physical or occupational therapy
      • Documentation should support that therapy services began within 36 hours from midnight of the day of admission to the IRF
         
  • Billing and/or Coding
    • The IRF-PAI should generally be included in the patient’s medical record
    • Documentation should support the discharge status code as billed on the claim. (Not a denial reason, but rather a correct coding statement.)

References

5CHG3 — Medical Review HIPPS Code Change Due to Partial Denial of Therapy

Reason for Denial
The services billed were paid at a lower payment level. Based on medical review of the records submitted, some of the therapy visits billed were not allowed. Reimbursement was adjusted due to a partial denial of therapy and the original HIPPS code was changed.

How to Avoid This Denial
Under the Prospective Payment System (PPS), Medicare reimbursement rates are based on the patient’s health condition and care needs. In order to receive a higher level of payment based on therapy services, there should be an adequate number of payable therapy visits to meet the threshold. This may include one type of therapy or a combination of occupational, speech-language pathology, or physical therapy services.

  • Submit orders to cover the therapy visits billed
  • Submit documentation to support the need for skilled therapy services
  • Submit all documentation related to the therapy services rendered

Resource: Outcome and Assessment Information Set Implementation Manual at www.cms.gov/oasis.


5D199/5H199 — Billing Error

Reason for Denial
The services billed were not covered because the documentation provided did not support the claim as billed by the provider.

How to Avoid This Denial

  • Check all bills for accuracy prior to submitting to Medicare
  • Ensure that the documentation submitted, in response to the ADR, corresponds with the date that the service was rendered, and the dates of service billed

Resources

Education

Palmetto GBA offers providers selected for TPE an individualized education session to discuss each claim denial. This is an opportunity to learn how to identify and correct claim errors. A variety of education methods are offered such as webinar sessions, web-based presentations, or teleconferences. Other education methods may also be available. Providers do not have to be selected for TPE to request education. If education is desired, please complete the Education Request Form.

Next Steps
Providers found to be non-compliant (major risk category/denial rate of 21–100 percent) at the completion of TPE Probe 1 will advance to Probe 2, and providers found to be non-compliant (major risk category/denial rate of 21–100 percent) at the completion of TPE Probe 2 will advance to Probe 3 of TPE after at least 45 days from completing the 1:1 post-probe education call date.


Was this article helpful?