Pre-Payment Review Results for DRG 885 Psychoses for July to September 2024

Published 11/12/2024

Pre-Payment Review Results for Diagnosis Related Group (DRG) 885 Psychoses for Targeted Probe and Educate (TPE) for July to September 2024

The Centers for Medicare & Medicaid Services (CMS) implemented the TPE process for DRG 885 Psychoses. The reviews with edit effectiveness are presented here for Alabama, Georgia and Tennessee.

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
12 11 1 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
436 21 5% $5,457,184.15 203,469.44 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
Ala. 12 11 1 0
Ga. 0 0 0 0
Tenn. 0 0 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
Ala. 436 21 5% $5,457,184.15 $203,469.44 4%
Ga. 0 0 0% $0.00 $0.00 0%
Tenn. 0 0 0% $0.00 $0.00 0%

Risk Category
The categories for DRG 885 Psychoses are defined as:

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

Figure 1. Risk Category for DRG 885.
Pie chart showing 92% minor findings and 8% major findings

Top Denial Reasons

Table 5. Top Denial Reasons.
Percent of Total Denials Denial Code Denial Description Number of Occurrences
50% 56900 Auto Deny — Requested Records Not Submitted Timely 5
20% 5J502, 5K502 Information Submitted Does Not Support Dates Billed 2
10% 5D700 No Valid Plan of Treatment Present 1
10% 5D800 Inpatient Psychiatric Services Not Medically Necessary 1
10% 5D650, 5H650 No Valid Certification/Recertification Present 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 Additional Documentation Request (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

5J502/5K502 — Information Submitted Does Not Support Dates Billed

Reason for Denial
The claim has been fully denied as the documentation submitted for review was not for the billing period requested in the additional documentation request (ADR). As a result, there were no orders for services or documentation of medical necessity for services billed.

How to Avoid This Denial

  • Ensure that the correct documentation is submitted for medical review by developing a procedure for staff to follow when preparing information in response to an ADR
  • Ensure documentation is for the DOS requested in the ADR
  • Ensure the documentation is for the beneficiary listed in the ADR

Resources

5D700 — No Valid Plan of Treatment Present 

Reason for Denial
The service(s) billed (was/were) not covered because a valid treatment plan established and approved by a physician was not included in the medical records submitted for review as required by Medicare.

How to Avoid This Denial
In order to avoid unnecessary denials for this reason, when responding to an Additional Documentation Request (ADR), the provider should ensure that the appropriate treatment plan is included and that it is signed by the physician and the mental health professionals contributing to it.

The treatment plan should be developed within the first three days of admission. The focus should be individualized to the patient’s specific strengths and problems as identified in the physician’s psychiatric evaluation, psychosocial and nursing assessments. It should contain a substantiated diagnosis; both short-term and long-range measurable, functional, time-framed goals directed at the individual problems identified as the cause for the patient’s admission; a list of any specific treatment modalities to be utilized in the active treatment of the patient; and a listing of the responsibilities of each member of the treatment team as he/she relates to the plan.

Treatment plan updates should show the treatment plan to be reflective of active treatment, as indicated by documentation of changes in the type, amount, frequency, and duration of the treatment services rendered as the patient moves toward expected outcomes. Treatment plan updates should be documented at least weekly, as the physician and treatment team assess the patient’s current clinical status and make necessary changes. Lack of progress and its relationship to active treatment and reasonable expectation of improvement should also be noted.

Resources

 5D800 — Inpatient Psychiatric Services Not Medically Necessary

Reason for Denial
Documentation submitted for review did not support the medical necessity for inpatient psychiatric services. 

How to Avoid This Denial
In order to avoid denials for this reason, the documentation must provide clear evidence that the acute psychiatric condition being evaluated or treated requires active treatment, including a combination of services such as intensive nursing and medical intervention, psychotherapy, occupational and activity therapy. Patients must require inpatient psychiatric hospitalization services at levels of intensity and frequency exceeding what may be rendered in an outpatient setting, including psychiatric partial hospitalization. There must be evidence of failure at, inability to benefit from, or unacceptable risk in an outpatient treatment setting. 

In addition, you should submit a complete Psychiatric Evaluation. This evaluation should be completed within 60 hours of the patient’s admission to the Psychiatric facility. It should include a medical history, record of mental status; note the onset of the current illness and circumstances leading to admission; describe the behaviors and attitudes of the patient; estimate the intellectual functioning, memory and orientation; provide an inventory of the patient’s assets in a descriptive fashion. In addition to the evaluation, progress notes from all modalities should be submitted in the medical record.

Resources

5D650/ 5H650 — No Valid Certification/Recertification Present

Reason for Denial
The Inpatient Psychiatric (IPF) claim was not covered because a valid certification/recertification signed by the physician was not included in the medical records submitted for review as required by Medicare.

How to Avoid This Denial
In order to avoid unnecessary denials for this reason, when responding to an ADR, the provider should ensure that the appropriate documentation to support certification/recertification is included and that it is signed by the mental health physician. A nonphysician provider (NPP) may not certify IPF claims. 

The initial certification should be completed at the time of admission or as soon thereafter as the patient’s condition reasonably allows. The physician must provide documentation that the services to be furnished on an inpatient basis can reasonably be expected to improve the patient’s condition or are for diagnostic study. There is no particular language or format required for the certification. It may be submitted on provider generated forms, in progress notes, in the records relating to the stay in question, however, it must be signed by the physician. If the certification is delayed it must be submitted with an explanation or other relevant evidence to justify the delay. 

Recertification should support that all services provided since the previous certification/recertification were, and continue to be, medically necessary that treatment is expected to improve the patient’s condition or is for diagnostic study. There should be documentation that the patient continues to require, on a daily basis, active treatment, and the supervision of inpatient psychiatric staff. The first recertification must be completed as of the 12th day of hospitalization. Each subsequent certification may be at intervals established by the psychiatric facility on a case-by-case basis; however, the interval is to be no longer than 30 days.

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.


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