Medical Review

Published 04/21/2022

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


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 RequestedTargeted 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 ChecklistOutpatient 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 OverviewDiagnosis Related Group (DRG 470) Reason Code CrosswalkNeulasta 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 SheetThe Prior Authorization (PA) Program for Certain Hospital Outpatient Department (OPD) Services Operational GuideesMD for the Review Choice Demonstration (RCD) and the Outpatient Department (OPD) Prior Authorization (PA)Outpatient 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 ToolSpinal Cord Stimulator ChecklistCervical Discectomy ChecklistCervical 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 2021Claim 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, 2021Postpayment Service-Specific Probe Results for Bevacizumab (Avastin) for April through June 2021RhinoplastyPostpayment Service-Specific Probe Results for Outpatient Rehabilitation Services: Manual Therapy for January through March 2021Implantation of Spinal NeurostimulatorPostpayment Service-Specific Probe Results for Therapeutic Exercise for April through June 2021Therapy Review Reason Codes and StatementsPostpayment Service-Specific Probe Results for Outpatient Rehabilitation Services: Manual Therapy for April through June 2021Access TPE Letters Electronically: Job AidVein Ablation and Related Services ChecklistCervical Fusion with Disc RemovalHospital Outpatient Department (OPD) Prior Authorization Exemption ProcessMedicare Record Authentication: Tips for PhysiciansMedicare Medical Records: Signature Requirements, Acceptable and Unacceptable PracticesHypoglossal Nerve Stimulation for Obstructive Sleep ApneaPanniculectomy, Excision of Excess Skin and Subcutaneous Tissue (Including Lipectomy), and Related ServicesOutpatient Department Prior Authorization Exemption Pre-Payment Provider-Specific Probe Results for Outpatient HBO Therapy for September 2021 through March 2022Pre-Payment Provider-Specific Probe Results for Pembrolizumab (Keytruda) for September 2021 through March 2022Pre-Payment Provider-Specific Probe Results for DRG 885: Psychoses for September 2021 through March 2022Pre-Payment Provider-Specific Probe Results for Manual Therapy for September 2021 through March 2022Pre-Payment Provider-Specific Probe Results for Pegfilgrastim (Neulasta) for September 2021 through March 2022Pre-Payment Provider-Specific Probe Results for Neuromuscular Reeducation for September 2021 through March 2022Pre-Payment Provider-Specific Probe Results for Denosumab (Prolia) for September 2021 through March 2022Pre-Payment Provider-Specific Probe Results for Infliximab (Remicade) for September 2021 through March 2022Medicare Exemption: Prior Authorization of Certain Hospital Outpatient Services VideoMedicare Documentation Signature TimelinessResponding to a Palmetto GBA Additional Documentation RequestTargeted Probe and Educate Process ModuleMedical Review Program and Targeted Probe and Educate HandoutPostpayment Provider-Specific Probe Results for Skilled Nursing Facility for September 2021 Through March 2022Active Service-Specific Postpayment Medical ReviewsPostpayment Service-Specific Probe Review for Outpatient Rehabilitation Services, Therapeutic Exercises for January Through March 2021JJ Part A and Part B Targeted Probe and Educate Active Medical Review ListBlepharoplasty and Medical Necessity Module5D509: No Qualifying Hospital Stay Dates Were Shown in HIMR for This Skilled Nursing Facility Stay