Immunosuppressive Drugs Pre-Pay Review Quarterly Status Report
Below is the analysis of claim denials for immunosuppressive drugs HCPCS codes J7503, J7507, J7518, J7520, and J7527 reviewed between January 1 and March 31, 2024. The error rate for this quarter is 17.39%. The top five reasons for claim denials are as follows:
Rank | Reason | Percent |
---|---|---|
1. | The beneficiary was in an acute care hospital or skilled nursing facility on this date of service. | 28.57% |
2. | We did not receive any medical record documentation. | 21.43% |
3. | The documentation does not have a valid Standard Written Order (SWO). | 21.43% |
4. | The documentation submitted is incomplete. | 21.43% |
5. | Documentation does not include information that supports that the beneficiary had a Medicare approved transplant per LCD/Policy Article requirements. | 7.14% |
*The total percentage will be greater than 100% because some claims denied for multiple reasons.
**The error rate included is an overall average for the supplier specific reviews as a part of the Targeted Probe and Educate program. This is not meant to be an overall error rate for the HCPCS code or policy under medical record review.
Resources:
- Immunosuppressive Drugs Documentation Checklist
- Immunosuppressive Drugs – LCD (L33824)
- Immunosuppressive Drugs – Policy Article (A52474)
- Immunosuppressive Drug Medical Review Resources
- Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)
- Supplier Manual Chapter 3 – Supplier Documentation
Updated: May 21, 2024