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


-
5D164 - Documentation Does Not Support Medical Necessity5CHGE - 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 Billed5H164 - Documentation Does Not Support Medical Necessity5D501 - Billed in Error5D510 - There Was No Evidence of at Least Three Consecutive Day of Inpatient Hospital Stay5D169 - Services Not Documented5D165 - The Documentation Submitted Did Not Include the Required Certifications or Recertification5H151 - Units Billed More than Ordered5D161 - No Physician's Orders5H169 - Services Not Documented5H507 - SNF MDS Is Not in the National Repository5D920 - The Recommended Protocol Was Not Ordered and/or Followed5H165 - The Documentation Submitted Did Not Include the Required Certifications or Recertification5H161 - No Physician's Orders5H501 - Billed in Error5D002 - Agree With Provider (Beneficiary Liable)5D507 - SNF MDS Is Not in the National RepositoryTargeted 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 G0277Targeted Probe and Educate Progress Update: DRG 682-683Targeted Probe and Educate Progress Update: HBO Therapy G0277Targeted Probe and Educate Progress Update: Bevacizumab J0935Targeted 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 RequestedTargeted 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 ChecklistMedical 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 Department (OPD) Prior Authorization (PA) Required DocumentationOutpatient Hospital Department (OPD) Prior Authorization (PA) Fax NumberOutpatient Department Prior Authorization (OPD) eServices Submission GuideBlepharoplasty and Blepharoptosis RepairPrior Authorization for Certain Hospital Outpatient Department (OPD) Services TerminologyOutpatient Department (OPD) Prior Authorization (PA) Part 1 Program OverviewNeulasta Reason Code CrosswalkDiagnosis 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 CrosswalkMedical Review Part A Fact SheetAvastin - Denial Reason CrosswalkHyperbaric Oxygen Reason Code CrosswalkDenosumab (Prolia) J0897 Reason Code CrosswalkRemicade Reason Code CrosswalkRituxan Reason Code CrosswalkActive Service Specific Postpayment Medical ReviewsDrugs 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 GuideesMD for the Review Choice Demonstration (RCD) and the Outpatient Department (OPD) Prior Authorization (PA)97110 Therapeutic Exercise Postpayment Results for October to December 2020Botulinum Toxin InjectionsOutpatient Department (OPD) Prior Authorization (PA)Postpayment Service-Specific Probe Results for Home Health for October through December 2020ADRs for Outpatient Department Prior Authorization services (OPD PA) ServicesPanniculectomyCMS MLN Fact Sheet: Medical Record Maintenance and Access RequirementsPostpayment Service-Specific Probe Results for Manual Therapy for January through March 2021Outpatient Prior Authorization (OPA) Status ToolSpinal Cord Stimulator ChecklistSpinal 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 52NCD: NCD Denial: HCPCS, Diagnosis Matched National Coverage Determination (NCD) Table List ICD9-CM Deny CodesReason Code 55504: Line Denied Medical Necessity Was Not Supported as Outlined in Palmetto GBA's Local Coverage DeterminationReason Code 5H199: Billing ErrorReason Code 5DTDP: Dependent Services Denied (Qualifying Service Denied Technically)Reason Code 5D199: Billing ErrorReason Code 5DMDP: Dependent Services Denied (Qualifying Service Denied Medically)Reason Code 5J503: No Orders for Inpatient AdmissionReason Code 5H920: The Recommended Protocol Was Not Ordered and/or FollowedReason Code 5HDMP: Dependent Services Denied (Qualifying Service Denied Medically)Reason Code 5H920: The Recommended Protocol Was Not Ordered and/or FollowedReason Code 5HTDP: Dependent Services Denied (Qualifying Service Denied Technically)Reason Code 5X002: Agree with Provider (Beneficiary Liable)Reason Code 5D002 and 5D011: Agree with Provider (Beneficiary Liable) (Provider Liable)Reason Code 5D011: Agree with Provider (Provider Liable)Claim 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 HBO Therapy for April through June 2021Postpayment 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 Pegfilgrastim (Neulasta) for April through June 2021Postpayment Service-Specific Probe Results for Bevacizumab (Avastin) for January Through March 2021Postpayment Service-Specific Probe Results for HBO Therapy for January Through March 2021RhinoplastyImplantation of Spinal NeurostimulatorTherapy Review Reason Codes and StatementsAccess TPE Letters Electronically: Job AidVein Ablation and Related Services ChecklistCervical Fusion with Disc RemovalReason Code 55503: Line Denied Medical Necessity Was Not Supported as Outlined in Palmetto GBA's Local Coverage DeterminationHospital 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 ExemptionJM Parts A, B and Home Health and Hospice Targeted Probe and Educate Active Medical Review ListMedicare Exemption: Prior Authorization of Certain Hospital Outpatient Services VideoMedicare Documentation Signature TimelinessResponding to a Palmetto GBA Additional Documentation RequestPre-Payment Provider-Specific Probe Results for Bevacizumab (Avastin) 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 Rituximab (Rituxan) 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 2022Pre-Payment Results for DRG 885: Pyschosis for September 2021 Through March 2022Pre-Payment Provider-Specific Probe Results for Therapeutic Exercise 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 Manual Therapy for September 2021 Through March 2022Pre-Payment Provider-Specific Probe Results for Outpatient Hyperbaric Oxygen Therapy for September 2021 Through March 2022Targeted Probe and Educate Process ModulePre-Payment Provider-Specific Probe Results for Intensity Modulated Radiotherapy Planning for September 2021 Through March 2022Pre-Payment Provider-Specific Probe Results for Diagnostic Imaging: MLC Device(s) for Intensity Modulated Radiotherapy for September 2021 Through March 2022Medical Review Program and Targeted Probe and Educate HandoutPre-Payment Provider-Specific Probe Results for Pegfilgrastim (Neulasta) for September 2021 Through March 2022Postpayment Service-Specific Probe Results for Therapeutic Exercise for January Through March 2021Postpayment Service-Specific Probe Results: Pegfilgrastim (Neulasta) for January Through March 2021Postpayment Service-Specific Probe Results for Denosumab (Prolia) for January Through March 2021