Medical Review


Resumption of Postpayment Medical Reviews

As recently published at MACs Resume Medical Review on a Postpayment Basis, Medicare Administrative Contractors (MACs) have resumed fee-for-service medical review activities to protect the Medicare Trust Fund against inappropriate payments. Beginning on or after August 17, 2020, the MACs resumed with postpayment reviews of items and services provided before March 1, 2020.

You may receive an additional documentation request (ADR) requesting medical record documentation associated with a claim selected for a service-specific postpayment review. For more information about services under review and how to respond to an ADR, you may refer to the Receiving and Responding to a Palmetto GBA Additional Documentation Request (ADR) for Postpayment Review and Active Service Specific Postpayment Medical Reviews articles.

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


5D164 - Documentation Does Not Support Medical Necessity5D002/5D011 - Agree with Provider (Beneficiary Liable) (Provider Liable)5CHGE - DRG Code Changed to Reflect Actual Service Billed53NCD - NCD Denial - No Diagnosis/Documentation to Support Medical Necessity (Provider Liable) (Beneficiary Liable)5J502 - Information Submitted Does Not Support Dates Billed52NCD - NCD Denial - HCPCS/Diagnosis Matched National Coverage Determination (NCD) Table List ICD9-CM Deny Codes5D199 - Billing Error5H164 - Documentation Does Not Support Medical Necessity5H199 - Billing Error5J503 - No Orders for Inpatient Admission5D501 - Billed in Error5D510 - There Was No Evidence of at Least Three Consecutive Day of Inpatient Hospital Stay5DTDP - Dependent Services Denied (Qualifying Service Denied Technically)5X002 - Agree With Provider (Beneficiary Liable)5D169 - Services Not Documented5D151 - Units Billed More than OrderedClaim Selection Process for Targeted Probe and Educate (TPE): S B6000 vs. S B60015D165 - The Documentation Submitted Did Not Include the Required Certifications or Recertification5H920 - The Recommended Protocol Was Not Ordered and/or Followed5H151 - Units Billed More than Ordered5DMDP - Dependent Services Denied (Qualifying Service Denied Medically)5D011 - Agree With Provider (Provider Liable)5D161 - No Physician's Orders5H169 - Services Not Documented5H507 - SNF MDS Is Not in the National Repository5D920 - The Recommended Protocol Was Not Ordered and/or Followed5HTDP - Dependent Services Denied (Qualifying Service Denied Technically)5H165 - The Documentation Submitted Did Not Include the Required Certifications or Recertification5H161 - No Physician's Orders5H501 - Billed in Error5HDMP - Dependent Services Denied (Qualifying Service Denied Medically)5D002 - Agree With Provider (Beneficiary Liable)5D507 - SNF MDS Is Not in the National RepositoryTargeted Probe and Educate (TPE) ProcessTargeted Probe and Educate Progress Update: Infliximab J17455DOWN - Medical Review Downcode5D800 - Inpatient Psychiatric Services Not Medically NecessaryTargeted Probe and Educate Progress Update: DRG 470 - Major Joint ReplacementTargeted Probe and Educate Progress Update: Inpatient Rehab Facility A0604, B0604, C0604 and D0604Targeted Probe and Educate Progress Update: Rituximab J9310/J9312Targeted Probe and Educate Progress Update: Neuromuscular Re-education - 97112Targeted Probe and Educate Progress Update: DRG 291 Heart Failure and Shock with MCC and DRG 292 Heart Failure with CCTargeted Probe and Educate Progress Update: HBO Therapy G027755503 - Line Denied Medical Necessity Was Not Supported as Outlined in Palmetto GBA's Local Coverage Determinations (LCDs) L34428 and L34570Targeted Probe and Educate Progress Update: DRG 682-683Targeted Probe and Educate Progress Update: HBO Therapy G0277Targeted Probe and Educate Progress Update: Bevacizumab J0935Medical Review Administrative Relief Related to the Novel Coronavirus (COVID-19) PandemicTargeted Probe and Educate Progress Update: Rituximab J9310Targeted Probe and Educate Progress Update: DRG 291 Heart Failure and Shock with MCC and DRG 292 Heart Failure with CC5D162 - Provider Did Not Submit All Records Requested55504 - Line Denied Medical Necessity Was Not Supported as Outlined in Palmetto GBA's Local Coverage Determinations (LCDs) L34428 and L34570Targeted Probe and Educate Progress Update: Infliximab J17455H504 - Not Medically Reasonable and Necessary56900 - Auto Denial - Requested Records Not SubmittedTargeted Probe and Educate Progress Update: Skilled Nursing Facility (SNF)Targeted Probe and Educate Progress Update: Manual Therapy - 97140Targeted Probe and Educate Progress Update: Denosumab J0897Targeted Probe and Educate Progress Update: Manual TherapyTargeted Probe and Educate Progress Update: DRG 8855D504 - Not Medically Reasonable and Necessary5D650 - No Valid Certification/Recertification PresentTargeted Probe and Educate Progress Update: DRG 682/683 Renal Failure with MCC/CCTargeted Probe & Educate (TPE) Provider Contact5H162 - Provider Did Not Submit All Records Requested5J504 - Need for Services Not Medically and Reasonably Necessary5D200 - Therapy Procedure Non-Skilled5D503 - Not Medically Reasonable and NecessaryTargeted Probe and Educate Progress Update: Pegfilgrastim J2505Targeted Probe and Educate Progress Update: Pegfilgrastim J25055D700 - No Valid Plan of Treatment PresentTargeted Probe and Educate Progress Update: Therapeutic Exercise 97110Targeted Probe and Educate VideoTargeted Probe and Educate Progress Update: Therapeutic ExerciseTargeted Probe and Educate Progress Update: Bevacizumab J0935Palmetto GBA Partnering with Providers to Get it Right the First TimeOutpatient Therapy (OT) Exercises ChecklistHyperbaric Oxygen ChecklistMACs Resume Medical Review on a Post-Payment BasisMedical Review Intent to Reopen Process for Non-Receipt of Medical Record DenialsOutpatient Department Prior Authorization CalculatorOutpatient Department (OPD) Prior Authorizations (PA)Outpatient Department (OPD) Prior Authorization (PA) Alert!Prior Authorization Process for Certain Hospital Outpatient Department (OPD) Services Frequently Asked QuestionsOutpatient Prior Authorization (OPA) Status ToolOutpatient Department (OPD) Prior Authorization (PA) Required DocumentationOutpatient Hospital Department (OPD) Prior Authorization (PA) Fax NumberOutpatient Department Prior Authorization (OPD) eServices Submission GuideBlepharoplasty and Blepharoptosis RepairRhinoplastyPrior Authorization for Certain Hospital Outpatient Department (OPD) Services TerminologyOutpatient Department (OPD) Prior Authorization (PA) Part 1 Program OverviewOutpatient Department (OPD) Prior Authorization (PA) ExemptionNeulasta Reason Code CrosswalkDiagnosis Related Group (DRG) 885 ChecklistDiagnosis Related Group (DRG) 470 ChecklistDiagnosis Related Group (DRG 470) Reason Code CrosswalkDiagnosis Related Group (DRG) Coding ChecklistOutpatient Therapy: Denial Reason Code CrosswalkDiagnosis Related Group (DRG) 885 Reason Code CrosswalkMedicare Documentation Signature TimelinessMedical Review Part A Fact SheetAvastin - Denial Reason CrosswalkHyperbaric Oxygen Reason Code CrosswalkDenosumab (Prolia) J0897 Reason Code CrosswalkRemicade Reason Code CrosswalkMedicare Documentation Signature TimelinessRituxan Reason Code CrosswalkActive Service Specific Postpayment Medical ReviewsDRG 470 - Major Joint Replacements or Reattachment of Lower ExtremityReceiving and Responding to a Palmetto GBA Additional Documentation Request (ADR) for Postpayment ReviewDrugs and Biologicals DenialsCharge Denial Rate (CDR) CalculatorWe Have Noticed a Significant Increase in 56900 Auto Denials - Requested Records Not SubmittedThe Prior Authorization (PA) Program for Certain Hospital Outpatient Department (OPD) Services Operational GuideVein Ablation and Related ServicesComplying with Medicare Signature RequirementsMedical Review Program and Targeted Probe and Educate HandoutMedicare Medical Records: Signature Requirements, Acceptable and Unacceptable PracticesTargeted 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 Physicians97110 Therapeutic Exercise Postpayment Results for October to December 2020PanniculectomyBotulinum Toxin InjectionsOutpatient Department (OPD) Prior Authorization (PA)ADRs for Outpatient Department Prior Authorization services (OPD PA) ServicesPost Payment Service-Specific Probe Results for Home Health for October through December 2020